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Luo Y, Lu K, Liu G, Wang J, Laurent I, Zhou X. The Effects of Novel Antidiabetic Drugs on Albuminuria in Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Clin Drug Investig 2019; 38:1089-1108. [PMID: 30255388 DOI: 10.1007/s40261-018-0707-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVE The effects of novel antidiabetic drugs, including sodium-glucose cotransporter 2 (SGLT-2) inhibitors, glucagon-like peptide 1 (GLP-1) receptor agonists, and dipeptidyl peptidase 4 (DPP-4) inhibitors, on albuminuria in patients with type 2 diabetes mellitus (T2DM) are still controversial. Therefore, we performed a meta-analysis to evaluate the effects of novel antidiabetic drugs on albuminuria in patients with T2DM. METHODS We conducted a random-effects meta-analysis of randomized controlled trials (RCTs) by searching the MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases up to 16 August 2018. The effects of novel antidiabetic drugs on albuminuria were evaluated as percent changes from baseline to follow-up urinary albumin excretion/urinary albumin to creatinine ratio (UAE/UACR) levels in both the intervention and control groups. Data regarding percent changes were used to generate weighted mean differences (WMDs) and 95% confidence intervals (CIs). RESULTS In this meta-analysis, 26 RCTs involving 14,929 patients were included. Pooled analysis suggested that SGLT-2 inhibitors (WMD - 26.23%, 95% CI - 35.90 to - 16.56; p < 0.00001) and GLP-1 receptor agonists (WMD - 13.85%, 95% CI - 15.96 to - 11.74; p < 0.00001) were associated with a significant reduction in albuminuria compared with other conventional therapies or placebo. DPP-4 inhibitors (WMD - 6.19%, 95% CI - 14.03 to 1.66; p = 0.12) were not significantly associated with lower albuminuria than other conventional therapies or placebo. CONCLUSION This meta-analysis indicates that SGLT-2 inhibitors and GLP-1 receptor agonists were associated with a reduction in albuminuria compared with other conventional therapies or placebo, while DPP-4 inhibitors were not associated with albuminuria-reducing effects compared with other conventional therapies or placebo.
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Affiliation(s)
- Ya Luo
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Kai Lu
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Gang Liu
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Jing Wang
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Irakoze Laurent
- Department of Endocrinology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China
| | - Xiaoli Zhou
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, 400016, China.
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302
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Scheen AJ. Why not adding a glucose-lowering agent with proven cardioprotection in high-risk patients with type 2 diabetes at HbA1c target on metformin? Diabetes Res Clin Pract 2019; 147:169-171. [PMID: 30391502 DOI: 10.1016/j.diabres.2018.10.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 10/24/2018] [Indexed: 11/26/2022]
Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders and Clinical Pharmacology Unit, Liège University and Academic Hospital of Liège (CHU Liège), B-4000 Liège, Belgium.
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303
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Almutairi M, Al Batran R, Ussher JR. Glucagon-like peptide-1 receptor action in the vasculature. Peptides 2019; 111:26-32. [PMID: 30227157 DOI: 10.1016/j.peptides.2018.09.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 12/14/2022]
Abstract
Glucagon-like peptide-1 receptor (GLP-1R) agonists augment insulin secretion and are thus used clinically to improve glycemia in subjects with type 2 diabetes (T2D). As recent data reveal marked improvements in cardiovascular outcomes in T2D subjects treated with the GLP-1R agonists liraglutide and semaglutide in the LEADER and SUSTAIN-6 clinical trials respectively, there is growing interest in delineating the mechanism(s) of action for GLP-1R agonist-induced cardioprotection. Of importance, negligible GLP-1R expression in ventricular cardiac myocytes suggests that cardiac-independent actions of GLP-1R agonists may account for the reduced death rates from cardiovascular causes in T2D subjects enrolled in the LEADER trial. Conversely, vascular smooth muscle cells (VSMCs) appear to express the canonical GLP-1R, and GLP-1/GLP-1R agonists exhibit a number of salutary actions on the vascular endothelium that could potentially contribute to GLP-1R agonists directly improving cardiovascular outcomes in subjects with T2D. We review herein the described actions of GLP-1/GLP-1R agonists on the vascular endothelium, which include antiproliferative actions on VSMCs and endothelial cells, reductions in oxidative stress, and increases in nitric oxide generation. GLP-1 also increases microvascular recruitment and microvascular blood flow. Taken together, such actions may explain the antihypertensive and/or antiatherosclerotic actions attributed to GLP-1/GLP-1R agonists in preclinical and clinical studies. Nonetheless, further mechanistic studies are still necessary to determine the relative importance of such actions in accounting for reductions in macrovascular cardiovascular disease in human subjects with T2D treated with GLP-1R agonists.
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Affiliation(s)
- Malak Almutairi
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Rami Al Batran
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - John R Ussher
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB Canada; Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada.
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304
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Bailey CJ, Marx N. Cardiovascular protection in type 2 diabetes: Insights from recent outcome trials. Diabetes Obes Metab 2019; 21:3-14. [PMID: 30091169 DOI: 10.1111/dom.13492] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 07/29/2018] [Accepted: 08/04/2018] [Indexed: 02/06/2023]
Abstract
This review examines recent randomized controlled cardiovascular (CV) outcome trials of glucose-lowering therapies in type 2 diabetes and their impact on the treatment of patients with type 2 diabetes. The trials were designed to comply with regulatory requirements to confirm that major adverse cardiac events (MACE) are not detrimentally affected by such therapies. Trials involving dipeptidyl peptidase-4 (DPP-4) inhibitors did not alter a composite MACE outcome comprising CV deaths, non-fatal myocardial infarction and non-fatal stroke; however, the possibility that some members of this class might incur a small increased risk or worsening of heart failure cannot be excluded. Some studies on glucagon-like peptide-1 receptor agonists (liraglutide: LEADER trial; semaglutide: SUSTAIN-6 trial) found significant benefits for MACE, while treatment with sodium-glucose co-transporter-2 inhibitors (empagliflozin: EMPA-REG OUTCOME trial; canagliflozin: CANVAS trial) also significantly reduced MACE and reduced hospitalization for heart failure. Comparisons among trials are complicated by variance in the populations recruited, particularly CV status at randomization, and differences in trial design, data collection and analyses. A large proportion of patients recruited into these trials have previously experienced adverse CV events; thus, the therapies are mostly assessing secondary prevention of a further event. This contrasts with the overall type 2 diabetes population receiving glucose-lowering therapies, of whom the majority will not have had MACE and will be regarded as primary prevention. Overall, the trials provide reassuring evidence that new glucose-lowering medications do not adversely affect CV events and some of these agents may offer CV protection.
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Affiliation(s)
- Clifford J Bailey
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Nikolaus Marx
- Department of Internal Medicine I, RWTH Aachen University, Aachen, Germany
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305
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Matikainen N, Söderlund S, Björnson E, Pietiläinen K, Hakkarainen A, Lundbom N, Taskinen M, Borén J. Liraglutide treatment improves postprandial lipid metabolism and cardiometabolic risk factors in humans with adequately controlled type 2 diabetes: A single-centre randomized controlled study. Diabetes Obes Metab 2019; 21:84-94. [PMID: 30073766 PMCID: PMC6585708 DOI: 10.1111/dom.13487] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/26/2018] [Accepted: 07/26/2018] [Indexed: 12/15/2022]
Abstract
AIMS Patients with type 2 diabetes and non-alcoholic fatty liver disease (NAFLD) exhibit considerable residual risk for cardiovascular disease (CVD). There is, therefore, increasing interest in targeting postprandial lipid metabolism and remnant cholesterol. Treatment with the glucagon-like peptide 1 (GLP-1) analogue liraglutide reduces CVD risk by mechanisms that remain unexplained in part. Here we investigated the effects of liraglutide intervention on ectopic fat depots, hepatic lipogenesis and fat oxidation, postprandial lipid metabolism and glycaemia in humans with type 2 diabetes. METHODS The effect of liraglutide was investigated in 22 patients with adequately controlled type 2 diabetes. Patients were randomly allocated, in a single-blind fashion, to either liraglutide 1.8 mg or placebo once daily for 16 weeks. Because liraglutide is known to promote weight loss, the study included dietary counselling to achieve similar weight loss in the liraglutide and placebo groups. Cardiometabolic responses to a high-fat mixed meal were measured before and at the end of the liraglutide intervention. RESULTS Weight loss at Week 16 was similar between the groups: -2.4 kg (-2.5%) in the liraglutide group and -2.1 kg (-2.2%) in the placebo group. HBA1c improved by 6.4 mmol/mol (0.6%) in the liraglutide group (P = 0.005). Liver fat decreased in both groups, by 31% in the liraglutide group and by 18% in the placebo group, but there were no significant changes in the rate of hepatic de novo lipogenesis or β-hydroxybutyrate levels, a marker of fat oxidation. We observed significant postprandial decreases in triglycerides only in plasma, chylomicrons and VLDL, and remnant particle cholesterol after treatment in the liraglutide group. Fasting and postprandial apoCIII concentrations decreased after liraglutide intervention and these changes were closely related to reduced glycaemia. In relative importance analysis, approximately half of the changes in postprandial lipids were explained by reductions in apoCIII concentrations, whereas less than 10% of the variation in postprandial lipids was explained by reductions in weight, glycaemic control, liver fat or postprandial insulin responses. CONCLUSIONS Intervention with liraglutide for 16 weeks produces multiple improvements in cardiometabolic risk factors that were not seen in the placebo group, despite similar weight loss. Of particular importance was a marked reduction in postprandial atherogenic remnant particles. The underlying mechanism may be improved glycaemic control, which leads to reduced expression of apoCIII, a key regulator of hypertriglyceridaemia in hyperglycaemic patients.
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Affiliation(s)
- Niina Matikainen
- Research Programs Unit, Diabetes and Obesity, Department of Internal MedicineHelsinki University Hospital, University of HelsinkiHelsinkiFinland
- Endocrinology, Abdominal CenterHelsinki University HospitalHelsinkiFinland
| | - Sanni Söderlund
- Research Programs Unit, Diabetes and Obesity, Department of Internal MedicineHelsinki University Hospital, University of HelsinkiHelsinkiFinland
| | - Elias Björnson
- Department of Molecular and Clinical MedicineUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
| | - Kirsi Pietiläinen
- Research Programs Unit, Diabetes and Obesity, Department of Internal MedicineHelsinki University Hospital, University of HelsinkiHelsinkiFinland
- Endocrinology, Abdominal CenterHelsinki University HospitalHelsinkiFinland
| | - Antti Hakkarainen
- HUS Medical Imaging Center, RadiologyHelsinki University Hospital, University of HelsinkiHelsinkiFinland
| | - Nina Lundbom
- HUS Medical Imaging Center, RadiologyHelsinki University Hospital, University of HelsinkiHelsinkiFinland
| | - Marja‐Riitta Taskinen
- Research Programs Unit, Diabetes and Obesity, Department of Internal MedicineHelsinki University Hospital, University of HelsinkiHelsinkiFinland
| | - Jan Borén
- Department of Molecular and Clinical MedicineUniversity of Gothenburg and Sahlgrenska University HospitalGothenburgSweden
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306
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Jialal I, Chaudhuri A. Targeting inflammation to reduce ASCVD in type 2 diabetes. J Diabetes Complications 2019; 33:1-3. [PMID: 30514609 DOI: 10.1016/j.jdiacomp.2018.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 10/31/2018] [Accepted: 11/01/2018] [Indexed: 01/12/2023]
Abstract
ASCVD is the leading cause of mortality in T2DM. Inflammation appears to be pivotal in the genesis of ASCVD. As T2DM is also a pro-inflammatory state, our aim was to determine the benefit of anti-inflammatory strategies on ASCVD in T2DM. PubMed searches were conducted using the keywords of T2DM, ASCVD, Inflammation and clinical trials. Our data review suggests that the Mediterranean diet, GLP1 receptor agonists and a monoclonal antibody against IL-1 reduces ASCVD events in T2DM. The former 2 therapies appear to be safe. Anti-IL-1 therapy resulted in an increase mortality from infections. We conclude that only the Mediterranean diet and GLP1 receptor agonists can be safely incorporated into mainstay therapy for patients with T2DM to reduce ASCVD. Further studies are required with respect to biologics targeting Inflammation to establish benefit to risk ratio.
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Affiliation(s)
- Ishwarlal Jialal
- VA Medical Center, Mather, CA, United States of America; California Northstate University College of Medicine, Elk Grove, CA, United States of America.
| | - Ajay Chaudhuri
- University at Buffalo, Buffalo, NY, United States of America
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307
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Abstract
DPP-4 inhibitors were introduced for the treatment of type 2 diabetes in 2006. They stimulate insulin secretion and inhibit glucagon secretion by elevating endogenous GLP-1 concentrations without an intrinsic hypoglycaemia risk. Their efficacy potential to lower HbA1c is in the range between 0.5 and 1.0% and their safety profile is favorable. DPP-4 inhibitors are body weight neutral and they have demonstrated cardiovascular safety. Most compounds can be used in impaired renal function. Guidelines suggest the additional use of DPP-4 inhibitors after metformin failure in patients that do not require antidiabetic therapy with proven cardiovascular benefit. Recently, DPP-4 inhibitors have increasingly replaced sulfonylureas as second line therapy after metformin failure and many metformin/DPP-4 inhibitor fixed dose combinations are available. In later stages of type 2 diabetes, DPP-4 inhibitors are also recommended in the guidelines in triple therapies with metformin and SGLT-2 inhibitors or with metformin and insulin. A treatment with DPP-4 inhibitors should be stopped when GLP-1 receptor agonists are used. DPP-4 inhibitors can be used as monotherapy when metformin is contraindicated or not tolerated. Some studies have shown value of initial metformin-DPP-4 inhibitor combination therapy in special populations. This article gives an overview on the clinical use of DPP-4 inhibitors.
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308
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Sposito AC, Berwanger O, de Carvalho LSF, Saraiva JFK. GLP-1RAs in type 2 diabetes: mechanisms that underlie cardiovascular effects and overview of cardiovascular outcome data. Cardiovasc Diabetol 2018; 17:157. [PMID: 30545359 PMCID: PMC6292070 DOI: 10.1186/s12933-018-0800-2] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 12/07/2018] [Indexed: 02/06/2023] Open
Abstract
Patients with type 2 diabetes (T2DM) have a substantial risk of developing cardiovascular disease. The strong connection between the severity of hyperglycaemia, metabolic changes secondary to T2DM and vascular damage increases the risk of macrovascular complications. There is a challenging demand for the development of drugs that control hyperglycaemia and influence other metabolic risk factors to improve cardiovascular outcomes such as cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, hospitalization for unstable angina and heart failure (major adverse cardiovascular events). In recent years, introduction of the new drug class of glucagon-like peptide-1 receptor agonists (GLP-1RAs) has changed the treatment landscape as GLP-1RAs have become well-established therapies in T2DM. The benefits of GLP-1RAs are derived from their pleiotropic effects, which include appetite control, glucose-dependent secretion of insulin and inhibition of glucagon secretion. Importantly, their beneficial effects extend to the cardiovascular system. Large clinical trials have evaluated the cardiovascular effects of GLP-1RAs in patients with T2DM and elevated risk of cardiovascular disease and the results are very promising. However, important aspects still require elucidation, such as the specific mechanisms involved in the cardioprotective effects of these drugs. Careful interpretation is necessary because of the heterogeneity across the trials concerning the definition of cardiovascular risk or cardiovascular disease, baseline characteristics, routine care and event rates. The aim of this review is to describe the main clinical aspects of the GLP-1RAs, compare them using data from both the mechanistic and randomized controlled trials and discuss potential reasons for improved cardiovascular outcomes observed in these trials. This review may help clinicians to decide which treatment is most appropriate in reducing cardiovascular risk in patients with T2DM.
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Affiliation(s)
- Andrei C Sposito
- Atherosclerosis and Vascular Biology Laboratory (AtheroLab), Cardiology Division, Faculty of Medical Sciences, State University of Campinas (Unicamp), 13084-971, Campinas, Sao Paulo, Brazil.
| | - Otávio Berwanger
- Academic Research Organization (ARO), Albert Einstein Hospital, Av. Albert Einstein 627, Sao Paulo, SP, 05651-901, Brazil
| | - Luiz Sérgio F de Carvalho
- Atherosclerosis and Vascular Biology Laboratory (AtheroLab), Cardiology Division, Faculty of Medical Sciences, State University of Campinas (Unicamp), 13084-971, Campinas, Sao Paulo, Brazil
| | - José Francisco Kerr Saraiva
- Cardiology Division, Pontifical Catholic University of Campinas Medicine School, Rua Engenheiro Carlos Stevenson 560, Campinas, Sao Paulo, 13092-132, Brazil
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309
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Kaneko S, Ueda Y, Tahara Y. GLP1 Receptor Agonist Liraglutide Is an Effective Therapeutic Option for Perioperative Glycemic Control in Type 2 Diabetes within Enhanced Recovery After Surgery (ERAS) Protocols. Eur Surg Res 2018; 59:349-360. [PMID: 30537714 DOI: 10.1159/000494768] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 10/23/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing profound stress responses following surgery [Wilmore and Kehlet: BMJ 2001; 322(7284): 473-6]. Glucagon-like peptide-1 receptor agonists (GLP-1RAgs), such as liraglutide, have recently been widely used as antidiabetic agents in patients with type 2 diabetes (T2D) because they maintain blood glucose at an ideal level throughout the day, including during postprandial periods, thereby improving hypoglycemia and body weight more than insulin therapies. Additionally, the administration of liraglutide may exert cardiovascular, renal, and cerebral protective effects in T2D patients. The use of GLP-1RAgs for perioperative glycemic control is sometimes considered to be controversial. METHODS The efficacy and safety of liraglutide therapy during perioperative glycemic control in elective surgery patients within ERAS protocols were compared with those of insulin therapy. Ninety adult T2D patients scheduled to undergo elective surgery within ERAS protocols were randomized and analyzed. Forty-nine subjects were prescribed liraglutide and 41 insulin therapy. Procedures comprised orthopedic, thoracic, urological, otolaryngological, hepatic resection, and gynecological breast surgeries. RESULTS Liraglutide was shown to be a more effective option than insulin therapy because (1) glycemic levels were more stable; (2) the number of patients requiring additional insulin according to the insulin sliding scale was significantly smaller (Fisher's exact test, p = 0.005); (3) the insulin dosage required on the day of surgery was significantly smaller (Fisher's exact, p = 0.004); (4) the additional insulin volume required was significantly less for patients throughout the perioperative period (Fisher's exact test, p = 0.001); and (5) while lean body mass remained the same, body fat measurements, particularly visceral fat, tended to decrease. CONCLUSIONS Based on the results of the present study and a recent large-scale clinical study showing cardiovascular and renal protective effects in T2D patients, we consider the administration of liraglutide within ERAS protocols for T2D patients to represent a more comprehensive suite of patient protection measures as a perioperative non-insulin agent, particularly in patients with limited exercise ability and those at risk of hypoglycemia.
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Affiliation(s)
- Shizuka Kaneko
- Division of Diabetes/Endocrinology/Lifestyle-Related Disease, Takatsuki Red Cross Hospital, Takatsuki, Japan,
| | - Youhei Ueda
- Division of Diabetes/Endocrinology/Lifestyle-Related Disease, Takatsuki Red Cross Hospital, Takatsuki, Japan
| | - Yumiko Tahara
- Division of Diabetes/Endocrinology/Lifestyle-Related Disease, Takatsuki Red Cross Hospital, Takatsuki, Japan
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310
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O’Brien MJ, Karam SL, Wallia A, Kang RH, Cooper AJ, Lancki N, Moran MR, Liss DT, Prospect TA, Ackermann RT. Association of Second-line Antidiabetic Medications With Cardiovascular Events Among Insured Adults With Type 2 Diabetes. JAMA Netw Open 2018; 1:e186125. [PMID: 30646315 PMCID: PMC6324353 DOI: 10.1001/jamanetworkopen.2018.6125] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 10/25/2018] [Indexed: 12/20/2022] Open
Abstract
Importance Understanding cardiovascular outcomes of initiating second-line antidiabetic medications (ADMs) may help inform treatment decisions after metformin alone is not sufficient or not tolerated. To date, no studies have compared the cardiovascular effects of all major second-line ADMs during this early decision point in the pharmacologic management of type 2 diabetes. Objective To examine the association of second-line ADM classes with major adverse cardiovascular events. Design, Setting, and Participants Retrospective cohort study among 132 737 insured adults with type 2 diabetes who started therapy with a second-line ADM after taking either metformin alone or no prior ADM. This study used 2011-2015 US nationwide administrative claims data. Data analysis was performed from January 2017 to October 2018. Exposures Dipeptidyl peptidase 4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, sodium-glucose cotransporter 2 (SGLT-2) inhibitors, thiazolidinediones (TZDs), basal insulin, and sulfonylureas or meglitinides (both referred to as sulfonylureas hereafter). The DPP-4 inhibitors served as the comparison group in all analyses. Main Outcomes and Measures The primary outcome was time to first cardiovascular event after starting the second-line ADM. This composite outcome was based on hospitalization for the following cardiovascular conditions: congestive heart failure, stroke, ischemic heart disease, or peripheral artery disease. Results Among 132 737 insured adult patients with type 2 diabetes (men, 55%; aged 45-64 years, 58%; white, 63%), there were 3480 incident cardiovascular events during 169 384 person-years of follow-up. Patients were censored after the first cardiovascular event, discontinuation of insurance coverage, transition from International Classification of Diseases, Ninth Revision (ICD-9) to end of ICD-9 coding, or 2 years of follow-up. After adjusting for patient, prescriber, and health plan characteristics, the risk of composite cardiovascular events after starting GLP-1 receptor agonists was lower than DPP-4 inhibitors (hazard ratio [HR], 0.78; 95% CI, 0.63-0.96), but this finding was not significant in all sensitivity analyses. Cardiovascular event rates after starting treatment with SGLT-2 inhibitors (HR, 0.81; 95% CI, 0.57-1.53) and TZDs (HR, 0.92; 95% CI, 0.76-1.11) were not statistically different from DPP-4 inhibitors. The comparative risk of cardiovascular events was higher after starting treatment with sulfonylureas (HR, 1.36; 95% CI, 1.23-1.49) or basal insulin (HR, 2.03; 95% CI, 1.81-2.27) than DPP-4 inhibitors. Conclusions and Relevance Among insured adult patients with type 2 diabetes initiating second-line ADM therapy, the short-term cardiovascular outcomes of GLP-1 receptor agonists, SGLT-2 inhibitors, and DPP-4 inhibitors were similar. Higher cardiovascular risk was associated with use of sulfonylureas or basal insulin compared with newer ADM classes. Clinicians may consider prescribing GLP-1 receptor agonists, SGLT-2 inhibitors, or DPP-4 inhibitors more routinely after metformin rather than sulfonylureas or basal insulin.
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Affiliation(s)
- Matthew J. O’Brien
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Susan L. Karam
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amisha Wallia
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Raymond H. Kang
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew J. Cooper
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nicola Lancki
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Margaret R. Moran
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Now with Oak Street Health, Chicago, Illinois
| | - David T. Liss
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Ronald T. Ackermann
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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311
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Andrikou E, Tsioufis C, Andrikou I, Leontsinis I, Tousoulis D, Papanas N. GLP-1 receptor agonists and cardiovascular outcome trials: An update. Hellenic J Cardiol 2018; 60:347-351. [PMID: 30528435 DOI: 10.1016/j.hjc.2018.11.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/09/2018] [Accepted: 11/14/2018] [Indexed: 12/17/2022] Open
Abstract
Major cardiovascular (CV) outcome trials with glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are currently available. These agonists have proven their CV safety, in harmony with the US Food and Drug Administration (FDA) recommendation for antidiabetic drugs. The potential cardioprotective effect of incretin-based therapies is attributed to their multiple non-glycaemic actions in the CV system, including changes in insulin resistance, weight loss, reduction in blood pressure, improved lipid profile and direct effects on the heart and vascular endothelium. Liraglutide, semaglutide and albiglutide have been demonstrated to reduce the risk of major adverse cardiac events (MACE), whereas lixisenatide and extended-release exenatide had a neutral effect. Thus, it is conceivable that there are different drug-specific properties across the class of GLP-1 RAs. In this review, we discuss the results of the five recently published randomised CV outcome trials with GLP-1 RAs, along with the potential differences and the pleiotropic actions of these agents on the CV system.
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Affiliation(s)
- Eirini Andrikou
- First Cardiology Department, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Costas Tsioufis
- First Cardiology Department, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece.
| | - Ioannis Andrikou
- First Cardiology Department, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Ioannis Leontsinis
- First Cardiology Department, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dimitrios Tousoulis
- First Cardiology Department, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Nikolaos Papanas
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece
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312
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Davies MJ, D'Alessio DA, Fradkin J, Kernan WN, Mathieu C, Mingrone G, Rossing P, Tsapas A, Wexler DJ, Buse JB. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2018; 61:2461-2498. [PMID: 30288571 DOI: 10.1007/s00125-018-4729-5] [Citation(s) in RCA: 748] [Impact Index Per Article: 124.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.
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Affiliation(s)
- Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK.
- Leicester Diabetes Centre, Leicester General Hospital, Leicester,, LE5 4PW, UK.
| | - David A D'Alessio
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Judith Fradkin
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Walter N Kernan
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, UZ Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Geltrude Mingrone
- Department of Internal Medicine, Catholic University, Rome, Italy
- Diabetes and Nutritional Sciences, King's College London, London, UK
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Apostolos Tsapas
- Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Deborah J Wexler
- Department of Medicine and Diabetes Unit, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - John B Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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313
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Diebold S, Moellmann J, Kahles F, Haj-Yehia E, Liehn EA, Nickel A, Lebherz C, Maack C, Marx N, Lehrke M. Myocardial infarction is sufficient to increase GLP-1 secretion, leading to improved left ventricular contractility and mitochondrial respiratory capacity. Diabetes Obes Metab 2018; 20:2911-2918. [PMID: 30033664 DOI: 10.1111/dom.13472] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 07/09/2018] [Accepted: 07/13/2018] [Indexed: 12/25/2022]
Abstract
Myocardial infarction causes rapid impairment of left ventricular function and requires a hypercontractile response of non-infarcted tissue areas to maintain haemodynamic stability. This compensatory adaptation is mediated by humoral, inflammatory and neuronal signals. GLP-1 is an incretin hormone with glucoregulatory and cardioprotective capacities and is secreted in response to nutritional and inflammatory stimuli. Inactivation of GLP-1 is caused by the ubiquitously present enzyme DPP-4. In this study, circulating concentrations of GLP-1 were assessed after myocardial infarction and were evaluated in the light of metabolism, left ventricular contractility and mitochondrial function. Circulating GLP-1 concentrations were markedly increased in patients with acute myocardial infarction. Experimental myocardial infarction by permanent LAD ligation proved sufficient to increase GLP-1 secretion in mice. This took place in a time-dependent manner, which coincided with the capacity of DPP-4 inhibition, by linagliptin, to augment left ventricular contractility in a GLP-1 receptor-dependent manner. Mechanistically, DPP-4 inhibition increased AMPK activity and stimulated the mitochondrial respiratory capacity of non-infarcted tissue areas. We describe a new functional relevance of inflammatory GLP-1 secretion for left ventricular contractility during myocardial infarction.
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Affiliation(s)
- Sebastian Diebold
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Julia Moellmann
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Florian Kahles
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Elias Haj-Yehia
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Elisa A Liehn
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Alexander Nickel
- Department of Translational Science, Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Corinna Lebherz
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Christoph Maack
- Department of Translational Science, Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Michael Lehrke
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
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314
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Santucci C, Franchi M, Staszewsky L, La Vecchia C, Latini R, Merlino L, Corrao G, Bosetti C. Incretin-based drugs and hospitalization for heart failure in the clinical practice: A nested case-control study. Diabetes Res Clin Pract 2018; 146:172-179. [PMID: 30332619 DOI: 10.1016/j.diabres.2018.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/01/2018] [Accepted: 10/11/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS There are concerns that incretin-based antidiabetic drugs - including dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists - increase the risk of hospitalization for heart failure (HF). To further analyse this issue, we conducted a nested case-control study within a cohort of antidiabetic users in a real world setting. METHODS AND RESULTS Within a cohort of 133,639 subjects with a first prescription of an antidiabetic drug (new-users) between 2010 and 2016 in Lombardy, Italy, and were followed-up to 2016, we identified 4057 subjects with a first hospitalization for HF and 80,450 controls matched on sex, age, and date of cohort-entry. The multivariate odds ratios (ORs) of HF in relation to current use of incretin-based drugs as compared to current use of two or more oral antidiabetics was 1.06 (95% confidence interval, CI, 0.83-1.35), with no evidence of a trend in risk with increasing duration of use. The corresponding ORs were 1.10 (95% CI 0.85-1.41) for DPP-4 inhibitors and 0.84 (95% CI 0.48-1.47) for GLP-1 receptor agonists. Estimates were consistent in various sensitivity analyses. CONCLUSIONS This study indicates that incretin-based drugs are not associated with an increased risk of hospitalization for HF, thus providing further reassurance on the cardiovascular safety of these antidiabetic drugs in the clinical practice.
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Affiliation(s)
- C Santucci
- Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - M Franchi
- National Centre for Healthcare Research & Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy; Laboratory of Healthcare Research & Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - L Staszewsky
- Department of Cardiovascular Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - C La Vecchia
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - R Latini
- Department of Cardiovascular Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - L Merlino
- Unità Organizzativa Governo dei Dati, delle Strategie e Piani del Sistema Sanitario, Regione Lombardia, Milan, Italy
| | - G Corrao
- National Centre for Healthcare Research & Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy; Laboratory of Healthcare Research & Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - C Bosetti
- Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.
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315
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Davies MJ, D'Alessio DA, Fradkin J, Kernan WN, Mathieu C, Mingrone G, Rossing P, Tsapas A, Wexler DJ, Buse JB. Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2018; 41:2669-2701. [PMID: 30291106 PMCID: PMC6245208 DOI: 10.2337/dci18-0033] [Citation(s) in RCA: 1691] [Impact Index Per Article: 281.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication, and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.
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Affiliation(s)
- Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, U.K.,Leicester Diabetes Centre, Leicester General Hospital, Leicester, U.K
| | - David A D'Alessio
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Judith Fradkin
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Walter N Kernan
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, UZ Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Geltrude Mingrone
- Department of Internal Medicine, Catholic University, Rome, Italy.,Diabetes and Nutritional Sciences, King's College London, London, U.K
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.,University of Copenhagen, Copenhagen, Denmark
| | - Apostolos Tsapas
- Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Deborah J Wexler
- Department of Medicine and Diabetes Unit, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - John B Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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316
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Das SR, Everett BM, Birtcher KK, Brown JM, Cefalu WT, Januzzi JL, Kalyani RR, Kosiborod M, Magwire ML, Morris PB, Sperling LS. 2018 ACC Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2018; 72:3200-3223. [PMID: 30497881 DOI: 10.1016/j.jacc.2018.09.020] [Citation(s) in RCA: 224] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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317
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Zhu B, Li Y, Mei W, He M, Ding Y, Meng B, Zhao H, Xiang G. Alogliptin improves endothelial function by promoting autophagy in perivascular adipose tissue of obese mice through a GLP-1-dependent mechanism. Vascul Pharmacol 2018; 115:55-63. [PMID: 30447331 DOI: 10.1016/j.vph.2018.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 10/22/2018] [Accepted: 11/13/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Perivascular adipose tissue (PVAT) regulates vascular function in a paracrine manner and the vasodilatory effect of PVAT on vessels is completely abolished in obesity. In addition, autophagy is required for maintaining biological function of PVAT and has been shown to be inhibited in obesity. The aim of this study was to explore whether alogliptin improves endothelial function by promoting autophagy in PVAT in obese mice. METHODS C57BL/6 mice were maintained on high fat diet with or without alogliptin intervention for 3 months. Vasorelaxation function of thoracic aorta with or without PVAT was determined. Autophagy related protein level of p62 and LC3B, along with phosphorylated mTOR (p-mTOR) were evaluated. In addition, the effects of alogliptin on autophagy were also investigated in cultured adipocytes. RESULTS The presence of PVAT significantly impaired endothelium-dependent vasodilation in obese mice and alogliptin intervention corrected this defect. Autophagy in PVAT was decreased in obese mice and alogliptin intervention activated autophagy. Activating autophagy in PVAT improved endothelium-dependent vasodilation while blocking it in PVAT impaired vasodilation function. Further, addition of glucagon-like peptide-1 (GLP-1) but not alogliptin alone activated autophagy. Moreover, GLP-1 and alogliptin co-treatment did not show additive effect on activating autophagy. CONCLUSIONS These results revealed that promoting autophagy in PVAT improved endothelial function in response to alogliptin intervention. Additionally, the beneficial effect of alogliptin intervention on PVAT was GLP-1 dependent.
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Affiliation(s)
- Biao Zhu
- Graduate School, Southern Medical University, Shatai Nan Road 1023, Guangzhou 510515, Guangdong Province, China; Department of Endocrinology, Wuhan General Hospital of Chinese People's Liberation Army, Wuluo Road 627, Wuhan 430070, Hubei Province, China
| | - Yixiang Li
- Department of Hematology and Medical Oncology, School of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Wen Mei
- Department of Endocrinology, Wuhan General Hospital of Chinese People's Liberation Army, Wuluo Road 627, Wuhan 430070, Hubei Province, China
| | - Mingjuan He
- Department of Endocrinology, Wuhan General Hospital of Chinese People's Liberation Army, Wuluo Road 627, Wuhan 430070, Hubei Province, China
| | - Yan Ding
- Department of Endocrinology, Wuhan General Hospital of Chinese People's Liberation Army, Wuluo Road 627, Wuhan 430070, Hubei Province, China
| | - Biying Meng
- Department of Endocrinology, Wuhan General Hospital of Chinese People's Liberation Army, Wuluo Road 627, Wuhan 430070, Hubei Province, China
| | - Hui Zhao
- Department of Endocrinology, Wuhan General Hospital of Chinese People's Liberation Army, Wuluo Road 627, Wuhan 430070, Hubei Province, China
| | - Guangda Xiang
- Graduate School, Southern Medical University, Shatai Nan Road 1023, Guangzhou 510515, Guangdong Province, China; Department of Endocrinology, Wuhan General Hospital of Chinese People's Liberation Army, Wuluo Road 627, Wuhan 430070, Hubei Province, China.
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318
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Moellmann J, Klinkhammer BM, Onstein J, Stöhr R, Jankowski V, Jankowski J, Lebherz C, Tacke F, Marx N, Boor P, Lehrke M. Glucagon-Like Peptide 1 and Its Cleavage Products Are Renoprotective in Murine Diabetic Nephropathy. Diabetes 2018; 67:2410-2419. [PMID: 30104246 DOI: 10.2337/db17-1212] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 07/27/2018] [Indexed: 11/13/2022]
Abstract
Incretin-based therapies, including glucagon-like peptide 1 (GLP-1) receptor agonists and dipeptidyl peptidase 4 (DPP-4) inhibitors, are potent glucose-lowering drugs. Still, only GLP-1 receptor agonists with close peptide homology to GLP-1 (liraglutide and semaglutide) but neither exenatide-based GLP-1 receptor agonists nor DPP-4 inhibitors were found to reduce cardiovascular events. This different response might relate to GLP-1 receptor-independent actions of GLP-1 caused by cleavage products only liberated by GLP-1 receptor agonists with close peptide structure to GLP-1. To test this hypothesis, we directly compared metabolic, renal, and cardiac effects of GLP-1 and its cleavage products in diabetic db/db mice. Using an adeno-associated viral vector system, we overexpressed DPP-4-resistant GLP-1 (7-37 Mut8) and the two GLP-1 cleavage products, GLP-1 (9-37) and GLP-1 (28-37), in diabetic db/db mice. Only GLP-1 (7-37 Mut8), but none of the cleavage products, significantly improved glucose metabolism. Still, all GLP-1 constructs significantly reduced tubulointerstitial renal damage, lowered expression of the tubular injury markers, and attenuated renal accumulation of macrophages and T cells. This was associated with a systemic immunomodulatory effect, which was similarly found in an acute renal ischemia/reperfusion injury model. In conclusion, GLP-1 cleavage products proved sufficient to mediate organ-protective effects, which might help to explain differences between GLP-1 receptor agonists.
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Affiliation(s)
- Julia Moellmann
- Department of Internal Medicine I, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Julia Onstein
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Robert Stöhr
- Department of Internal Medicine I, University Hospital RWTH Aachen, Aachen, Germany
| | - Vera Jankowski
- Institute for Molecular Cardiovascular Research, University Hospital RWTH Aachen, Aachen, Germany
| | - Joachim Jankowski
- Institute for Molecular Cardiovascular Research, University Hospital RWTH Aachen, Aachen, Germany
| | - Corinna Lebherz
- Department of Internal Medicine I, University Hospital RWTH Aachen, Aachen, Germany
| | - Frank Tacke
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital RWTH Aachen, Aachen, Germany
| | - Peter Boor
- Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
- Department of Internal Medicine II, Nephrology and Immunology, University Hospital RWTH Aachen, Aachen, Germany
- Electron Microscopy Facility, RWTH Aachen University, Aachen, Germany
| | - Michael Lehrke
- Department of Internal Medicine I, University Hospital RWTH Aachen, Aachen, Germany
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319
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Newman JD, Vani AK, Aleman JO, Weintraub HS, Berger JS, Schwartzbard AZ. The Changing Landscape of Diabetes Therapy for Cardiovascular Risk Reduction: JACC State-of-the-Art Review. J Am Coll Cardiol 2018; 72:1856-1869. [PMID: 30286929 PMCID: PMC6178226 DOI: 10.1016/j.jacc.2018.07.071] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 07/18/2018] [Accepted: 07/24/2018] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus (T2D) is a major risk factor for cardiovascular disease (CVD), the most common cause of death in T2D. Despite improved risk factor control, however, adults with T2D continue to experience substantial excess CVD risk. Until recently, however, improved glycemic control has not been associated with robust macrovascular benefit. The advent of 2 new classes of antihyperglycemic agents, the sodium-glucose cotransporter-2 inhibitors and the glucagon-like peptide-1 receptor agonists, and their respective large cardiovascular outcome trials, has led to a paradigm shift in how cardiologists and heath care practitioners conceptualize T2D treatment. Herein, the authors review the recent trial evidence, the potential mechanisms of action of the sodium-glucose cotransporter-2 inhibitors and the glucagon-like peptide-1 receptor agonists, safety concerns, and their use for the primary prevention of CVD as well as in diabetic patients with impaired renal function and heart failure.
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Affiliation(s)
- Jonathan D Newman
- Division of Cardiology and Center for the Prevention of Cardiovascular Disease, Department of Medicine, New York University Medical Center, New York, New York.
| | - Anish K Vani
- Division of Cardiology and Center for the Prevention of Cardiovascular Disease, Department of Medicine, New York University Medical Center, New York, New York
| | - Jose O Aleman
- Division of Endocrinology, New York University Medical Center, New York, New York
| | - Howard S Weintraub
- Division of Cardiology and Center for the Prevention of Cardiovascular Disease, Department of Medicine, New York University Medical Center, New York, New York
| | - Jeffrey S Berger
- Division of Cardiology and Center for the Prevention of Cardiovascular Disease, Department of Medicine, New York University Medical Center, New York, New York
| | - Arthur Z Schwartzbard
- Division of Cardiology and Center for the Prevention of Cardiovascular Disease, Department of Medicine, New York University Medical Center, New York, New York
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320
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Capozzi ME, DiMarchi RD, Tschöp MH, Finan B, Campbell JE. Targeting the Incretin/Glucagon System With Triagonists to Treat Diabetes. Endocr Rev 2018; 39:719-738. [PMID: 29905825 PMCID: PMC7263842 DOI: 10.1210/er.2018-00117] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/07/2018] [Indexed: 02/07/2023]
Abstract
Glucagonlike peptide 1 (GLP-1) receptor agonists have been efficacious for the treatment of type 2 diabetes due to their ability to reduce weight and attenuate hyperglycemia. However, the activity of glucagonlike peptide 1 receptor-directed strategies is submaximal, and the only potent, sustainable treatment of metabolic dysfunction is bariatric surgery, necessitating the development of unique therapeutics. GLP-1 is structurally related to glucagon and glucose-dependent insulinotropic peptide (GIP), allowing for the development of intermixed, unimolecular peptides with activity at each of their respective receptors. In this review, we discuss the range of tissue targets and added benefits afforded by the inclusion of each of GIP and glucagon. We discuss considerations for the development of sequence-intermixed dual agonists and triagonists, highlighting the importance of evaluating balanced signaling at the targeted receptors. Several multireceptor agonist peptides have been developed and evaluated, and the key preclinical and clinical findings are reviewed in detail. The biological activity of these multireceptor agonists are founded in the success of GLP-1-directed strategies; by including GIP and glucagon components, these multireceptor agonists are thought to enhance GLP-1's activities by broadening the tissue targets and synergizing at tissues that express multiple receptors, such at the brain and pancreatic islet β cells. The development and utility of balanced, unimolecular multireceptor agonists provide both a useful tool for querying the actions of incretins and glucagon during metabolic disease and a unique drug class to treat type 2 diabetes with unprecedented efficacy.
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Affiliation(s)
- Megan E Capozzi
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina
| | - Richard D DiMarchi
- Department of Chemistry, Indiana University, Bloomington, Indiana
- Novo Nordisk Research Center, Indianapolis, Indiana
| | - Matthias H Tschöp
- Institute for Diabetes and Obesity, Helmholtz Diabetes Center, Helmholtz Zentrum München, Neuherberg, Germany
- Division of Metabolic Diseases, Department of Medicine, Technische Universität München, Munich, Germany
| | - Brian Finan
- Novo Nordisk Research Center, Indianapolis, Indiana
| | - Jonathan E Campbell
- Duke Molecular Physiology Institute, Duke University, Durham, North Carolina
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321
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Glucagon-Like Peptide-1 Receptor Agonists and Cardiovascular Risk Reduction in Type 2 Diabetes Mellitus: Is It a Class Effect? Curr Cardiol Rep 2018; 20:113. [DOI: 10.1007/s11886-018-1051-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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322
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Comparing once-weekly semaglutide to incretin-based therapies in patients with type 2 diabetes: a systematic review and meta-analysis. DIABETES & METABOLISM 2018; 45:102-109. [PMID: 30243806 DOI: 10.1016/j.diabet.2018.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 09/05/2018] [Accepted: 09/10/2018] [Indexed: 12/27/2022]
Abstract
AIMS Our aim was to compare once-weekly semaglutide to incretin-based therapies - defined as either dipeptidyl peptidase-4 inhibitors (DPP-4i) or other glucagon-like peptide-1 receptor agonist (GLP-1RA) - in patients with type 2 diabetes. METHODS We searched for randomized trials comparing once-weekly semaglutide to other incretin-based therapies in patients with type 2 diabetes. We pooled trials that compared semaglutide to other GLP-1RA together, and those comparing semaglutide to DPP-4i together. The primary outcome was the change in haemoglobin A1c over time. RESULTS Five trials met our inclusion criteria. There was a significantly greater reduction in haemoglobin A1c favouring semaglutide when compared to other GLP-1RA or DPP-4i [MD (95% CI) = -0.38% (-0.62, -0.15) and -1.14% (-1.53, -0.75) respectively]. There was a significantly greater weight loss favouring semaglutide when compared to other GLP-1RA or DPP-4i [MD (95% CI) = -2.50 kg (-3.91, -1.09) and -3.19 kg (-3.66, -2.72) respectively]. The proportion of patients achieving glycaemic goals and goal weight loss was greater in semaglutide-treated patients when compared to either other GLP-1RA or DPP-4i. However, semaglutide-treated patients had a significantly higher incidence of gastrointestinal side effects. CONCLUSIONS While both once-weekly semaglutide and other incretin-based therapies can reduce haemoglobin A1c, semaglutide causes a more potent haemoglobin A1c reduction and greater weight loss when compared to other incretin-based therapies. However, this potent effect of semaglutide was associated with a higher incidence of gastrointestinal side effects. Additional studies are needed to determine whether this marked reduction in both haemoglobin A1c and body weight may translate into improved cardiovascular outcomes.
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323
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Zhang X, Shao F, Zhu L, Ze Y, Zhu D, Bi Y. Cardiovascular and microvascular outcomes of glucagon-like peptide-1 receptor agonists in type 2 diabetes: a meta-analysis of randomized controlled cardiovascular outcome trials with trial sequential analysis. BMC Pharmacol Toxicol 2018; 19:58. [PMID: 30223891 PMCID: PMC6142638 DOI: 10.1186/s40360-018-0246-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/28/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Efficacy trials showed that glucagon-like peptide-1 receptor (GLP1R) agonists reduced metabolic risk factors in addition to glucose lowering, but the cardiovascular and microvascular efficacy of this drug class remains to be determined. We aimed to evaluate the overall cardiovascular and microvascular efficacy of GLP1R agonists by performing a meta-analysis with trial sequential analysis. METHODS Randomized controlled, cardiovascular outcomes trials including at least 2000 patient-years' follow-up and 100 composite cardiovascular events were included. Trial sequential analysis (TSA) was performed and the quality of evidence was graded. RESULTS Thirty-three thousand four hundred fifty-seven patients and 4105 cardiovascular events from 4 large trials were included. GLP1R agonists were associated with a statistically significant reduction in risks for all-cause mortality (hazard ratio [HR]: 0.88, 95% CI: 0.81 to 0.95; number needed to treat [NNT]: 286 person-years), cardiovascular mortality (HR: 0.87, 95% CI: 0.79 to 0.96; NNT: 412 person-years), stroke (HR: 0.87, 95% CI: 0.76 to 0.98; NNT: 209 person-years) and the composite adverse cardiovascular outcome (MACE; HR: 0.91, 95% CI: 0.85 to 0.96; NNT: 241 person-years). The magnitude of benefit on MACE was attenuated in patients with a history of congestive heart failure (HR: 0.96, 95% CI: 0.85 to 1.08 with; HR: 0.87, 95% CI: 0.77 to 1.00 without). The risks for hospitalization for heart failure and myocardial infarction were not significantly different. The quality of the evidence was deemed as moderate to high based on GRADE approach. TSA provided firm evidence for a 10% reduction in all-cause mortality, a 15% reduction in MACE, and lack of a 15% reduction in hospitalization for heart failure, but evidence remains inconclusive for cardiovascular mortality and myocardial infarction. GLP1R agonists numerically reduced the rates for nephropathy but the risk for retinopathy was similar. CONCLUSIONS Meta-analysis with trial sequential analysis suggested that GLP1R agonists significantly reduced the risk for all-cause mortality and composite cardiovascular outcomes, but the reduction of cardiovascular mortality remains to be confirmed.
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Affiliation(s)
- Xiaowen Zhang
- Department of Endocrinology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008 China
| | - Fei Shao
- Department of Endocrinology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008 China
- Department of Endocrinology, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008 China
| | - Lin Zhu
- Department of Endocrinology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008 China
| | - Yuyang Ze
- Department of Endocrinology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008 China
| | - Dalong Zhu
- Department of Endocrinology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008 China
| | - Yan Bi
- Department of Endocrinology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008 China
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324
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Drucker DJ. The Ascending GLP-1 Road From Clinical Safety to Reduction of Cardiovascular Complications. Diabetes 2018; 67:1710-1719. [PMID: 30135132 DOI: 10.2337/dbi18-0008] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/01/2018] [Indexed: 11/13/2022]
Abstract
Glucagon-like peptide 1 (GLP-1) was originally identified as a gut-derived incretin hormone that lowered glycemia through potentiation of glucose-dependent insulin secretion. Subsequent studies expanded the actions of GLP-1 to include inhibition of glucagon secretion, gastric emptying, and appetite, collectively useful attributes for a glucose-lowering agent. The introduction of GLP-1 receptor (GLP-1R) agonists for the treatment of diabetes was associated with questions surrounding their safety, principally with regard to medullary thyroid cancer, pancreatitis, and pancreatic cancer, yet cardiovascular outcome trials subsequently revealed reductions in rates of stroke, myocardial infarction, and cardiovascular death with a paucity of major safety signals. We discuss the controversies, unanswered questions, and established use of GLP-1R agonists from a mechanistic and clinical perspective. We highlight methods for detection and cellular sites of GLP-1R expression, key uncertainties, recent insights, and experimental caveats surrounding the use of GLP-1R agonists for the treatment of diabetes and the reduction of diabetes-related complications.
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Affiliation(s)
- Daniel J Drucker
- Department of Medicine, Mount Sinai Hospital, Lunenfeld-Tanenbaum Research Institute, University of Toronto, Toronto, Ontario, Canada
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325
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Scheen AJ. Cardiovascular outcome studies in type 2 diabetes: Comparison between SGLT2 inhibitors and GLP-1 receptor agonists. Diabetes Res Clin Pract 2018; 143:88-100. [PMID: 29944969 DOI: 10.1016/j.diabres.2018.06.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/14/2018] [Accepted: 06/13/2018] [Indexed: 12/22/2022]
Abstract
Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) are two pharmacological classes that have proven their efficacy to reduce major cardiovascular events (MACEs) in patients with type 2 diabetes mellitus (T2DM) and established cardiovascular disease in large prospective cardiovascular outcome trials (CVOTs): EMPA-REG OUTCOME (empagliflozin), CANVAS (canagliflozin), LEADER (liraglutide) and SUSTAIN 6 (semaglutide). Some heterogeneity appears to exist between the various agents within the two pharmacological classes. Whether these positive results could be extrapolated to patients without cardiovascular disease is still unknown. The underlying mechanisms remain a matter of debate but appear to differ between SGLT2is and GLP-1RAs. One crucial question is which patient's characteristics should be taken into account to guide the choice between a SGLT2i or a GLP-1RA according to a personalized approach. Heart failure should encourage the use of a SGLT2i whereas moderate to severe chronic kidney disease should favour the prescription of a GLP-1RA. Despite the results of recent CVOTs, numerous patients who are good candidates for benefiting of these agents do not receive them in clinical practice. Currently, there is a paradigm shift in T2DM management, moving from a primary objective of glucose control to a cardiovascular and renal protection.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, University of Liège, Liège, Belgium; Clinical Pharmacology Unit, CHU Liège, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
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326
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Mather KJ, Considine RV, Hamilton L, Patel NA, Mathias C, Territo W, Goodwill AG, Tune JD, Green MA, Hutchins GD. Combination GLP-1 and Insulin Treatment Fails to Alter Myocardial Fuel Selection vs. Insulin Alone in Type 2 Diabetes. J Clin Endocrinol Metab 2018; 103:3456-3465. [PMID: 30020461 PMCID: PMC6126889 DOI: 10.1210/jc.2018-00712] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 07/12/2018] [Indexed: 12/25/2022]
Abstract
CONTEXT It is unclear if effects of glucagon-like peptide-1 (GLP-1) and clinically available GLP-1 agonists on the heart occur at clinical doses in humans, possibly contributing to reduced cardiovascular disease risk. OBJECTIVE To determine whether liraglutide, at clinical dosing, augments myocardial glucose uptake (MGU) alone or combined with insulin compared with insulin alone in metformin-treated type 2 diabetes mellitus (T2D). DESIGN In a randomized clinical trial of patients with T2D treated with metformin plus oral agents or basal insulin, myocardial fuel use was compared after 3 months of treatment with insulin detemir, liraglutide, or combination detemir plus liraglutide added to background metformin. MAIN OUTCOME MEASURES Myocardial blood flow (MBF), fuel selection, and rates of fuel use were evaluated using positron emission tomography, powered to demonstrate large effects. RESULTS MBF was greater in the insulin-treated groups [median (25th, 75th percentile): detemir, 0.64 mL/g/min (0.50, 0.69); liraglutide, 0.52 mL/g/min (0.46, 0.58); detemir plus liraglutide, 0.75 mL/g/min (0.55, 0.77); P = 0.035 comparing three groups, P = 0.01 comparing detemir groups to liraglutide alone]. There were no evident differences among groups in MGU [detemir, 0.040 µmol/g/min (0.013, 0.049); liraglutide, 0.055 µmol/g/min (0.019, 0.105); detemir plus liraglutide, 0.037 µmol/g/min (0.009, 0.046); P = 0.68 comparing three groups]. There were no treatment-group differences in measures of myocardial fatty acid uptake or handling, and no differences in total oxidation rate. CONCLUSION These observations argue against large effects of GLP-1 agonists on myocardial fuel metabolism as mediators of beneficial treatment effects on myocardial function and ischemia protection.
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Affiliation(s)
- Kieren J Mather
- Indiana University School of Medicine, Indianapolis, Indiana
- Correspondence and Reprint Requests: Kieren J. Mather, MD, Indiana University School of Medicine, 1120 West Michigan Street, CL365, Indianapolis, Indiana 46202. E-mail:
| | | | | | - Niral A Patel
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Carla Mathias
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Wendy Territo
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Adam G Goodwill
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Mark A Green
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Gary D Hutchins
- Indiana University School of Medicine, Indianapolis, Indiana
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327
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Cardiovascular benefits of GLP-1 agonists in type 2 diabetes: a comparative review. Clin Sci (Lond) 2018; 132:1699-1709. [DOI: 10.1042/cs20171299] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes (T2D) carries risks of both cardiovascular (CV) (myocardial infarction, stroke, and peripheral vascular disease) and microvascular (retinopathy/nephropathy/neuropathy) complications. Glucose-lowering is an effective strategy for preventing microvascular complications, but the extent to which it can reduce CV complications is less certain. Glucagon-like peptide-1 (GLP-1) agonists are potent glucose-lowering agents but also have potentially beneficial effects on other traditional (body weight, blood pressure (BP), and LDL cholesterol) and non-traditional risk factors (low grade inflammation and endothelial dysfunction). The results of four large CV outcome trials with GLP-1 agonists are now available. These have compared lixisenatide (ELIXA), liraglutide (LEADER), semaglutide (SUSTAIN-6), and long-acting exenatide (EXSCEL) with placebo and standard of care over 2–4 years; four others (including with dulaglutide and albiglutide) are ongoing. LEADER and SUSTAIN-6 have demonstrated reductions in rates of major adverse CV events with active GLP-1 treatment but ELIXA and EXSCEL have not. In this review, we discuss the mechanisms by which GLP-1 receptor agonists act on the CV system and the design and conduct of these trials. Contrary to the assertions that (a) all GLP-1 agonists reduce CV disease in T2D but to different extents or (b) the magnitude of CV protection is predominantly related to glucose-lowering, we argue that CV benefit is specific to agents that provide longer acting agonism at the GLP-1 receptor. The mechanisms involve reduction in body weight and BP, and lowering of LDL-cholesterol and glucose, but pleiotropic effects—including suppression of low grade inflammation, vasodilation, and natriuresis—are also likely relevant.
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328
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Wu L, Wang K, Wang W, Wen Z, Wang P, Liu L, Wang DW. Glucagon-like peptide-1 ameliorates cardiac lipotoxicity in diabetic cardiomyopathy via the PPARα pathway. Aging Cell 2018; 17:e12763. [PMID: 29659121 PMCID: PMC6052396 DOI: 10.1111/acel.12763] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2018] [Indexed: 12/13/2022] Open
Abstract
Lipotoxicity cardiomyopathy is the result of excessive accumulation and oxidation of toxic lipids in the heart. It is a major threat to patients with diabetes. Glucagon-like peptide-1 (GLP-1) has aroused considerable interest as a novel therapeutic target for diabetes mellitus because it stimulates insulin secretion. Here, we investigated the effects and mechanisms of the GLP-1 analog exendin-4 and the dipeptidyl peptidase-4 inhibitor saxagliptin on cardiac lipid metabolism in diabetic mice (DM). The increased myocardial lipid accumulation, oxidative stress, apoptosis, and cardiac remodeling and dysfunction induced in DM by low streptozotocin doses and high-fat diets were significantly reversed by exendin-4 and saxagliptin treatments for 8 weeks. We found that exendin-4 inhibited abnormal activation of the (PPARα)-CD36 pathway by stimulating protein kinase A (PKA) but suppressing the Rho-associated protein kinase (ROCK) pathway in DM hearts, palmitic acid (PA)-treated rat h9c2 cardiomyocytes (CMs), and isolated adult mouse CMs. Cardioprotection in DM mediated by exendin-4 was abolished by combination therapy with the PPARα agonist wy-14643 but mimicked by PPARα gene deficiency. Therefore, the PPARα pathway accounted for the effects of exendin-4. This conclusion was confirmed in cardiac-restricted overexpression of PPARα mediated by adeno-associated virus serotype-9 containing a cardiac troponin T promoter. Our results provide the first direct evidence that GLP-1 protects cardiac function by inhibiting the ROCK/PPARα pathway, thereby ameliorating lipotoxicity in diabetic cardiomyopathy.
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Affiliation(s)
- Lujin Wu
- Division of Cardiology; Department of Internal Medicine; Tongji Hospital; Tongji Medical College; Huazhong University of Science and Technology; Wuhan China
- Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders; Wuhan China
| | - Ke Wang
- Department of Neonatal Medicine; The Central Hospital of Wuhan; Tongji Medical College; Huazhong University of Science and Technology; Wuhan China
| | - Wei Wang
- Division of Cardiology; Department of Internal Medicine; Tongji Hospital; Tongji Medical College; Huazhong University of Science and Technology; Wuhan China
- Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders; Wuhan China
| | - Zheng Wen
- Division of Cardiology; Department of Internal Medicine; Tongji Hospital; Tongji Medical College; Huazhong University of Science and Technology; Wuhan China
- Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders; Wuhan China
| | - Peihua Wang
- Division of Cardiology; Department of Internal Medicine; Tongji Hospital; Tongji Medical College; Huazhong University of Science and Technology; Wuhan China
- Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders; Wuhan China
| | - Lei Liu
- Division of Cardiology; Department of Internal Medicine; Tongji Hospital; Tongji Medical College; Huazhong University of Science and Technology; Wuhan China
- Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders; Wuhan China
| | - Dao Wen Wang
- Division of Cardiology; Department of Internal Medicine; Tongji Hospital; Tongji Medical College; Huazhong University of Science and Technology; Wuhan China
- Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders; Wuhan China
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329
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van Baar MJB, van Ruiten CC, Muskiet MHA, van Bloemendaal L, IJzerman RG, van Raalte DH. SGLT2 Inhibitors in Combination Therapy: From Mechanisms to Clinical Considerations in Type 2 Diabetes Management. Diabetes Care 2018; 41:1543-1556. [PMID: 30030256 DOI: 10.2337/dc18-0588] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 05/12/2018] [Indexed: 02/03/2023]
Abstract
The progressive nature of type 2 diabetes (T2D) requires practitioners to periodically evaluate patients and intensify glucose-lowering treatment once glycemic targets are not attained. With guidelines moving away from a one-size-fits-all approach toward setting patient-centered goals and allowing flexibility in choosing a second-/third-line drug from the growing number of U.S. Food and Drug Administration-approved glucose-lowering agents, keen personalized management in T2D has become a challenge for health care providers in daily practice. Among the newer generation of glucose-lowering drug classes, sodium-glucose cotransporter 2 inhibitors (SGLT2is), which enhance urinary glucose excretion to lower hyperglycemia, have made an imposing entrance to the T2D treatment armamentarium. Given their unique insulin-independent mode of action and their favorable efficacy-to-adverse event profile and given their marked benefits on cardiovascular-renal outcome in moderate-to-high risk T2D patients, which led to updates of guidelines and product monographs, the role of this drug class in multidrug regimes is promising. However, despite many speculations based on pharmacokinetic and pharmacodynamic properties, physiological reasoning, and potential synergism, the effects of these agents in terms of glycemic and pleiotropic efficacy when combined with other glucose-lowering drug classes are largely understudied. In this perspective, we review the currently emerging evidence, discuss prevailing hypotheses, and elaborate on necessary future studies to clarify the potential risks and benefits of using an SGLT2i in dual combination with metformin and triple combination with a glucagon-like peptide 1 receptor agonist, dipeptidyl peptidase 4 inhibitor, or other glucose-lowering agent that is recommended by the American Diabetes Association and European Association for the Study of Diabetes (i.e., a sulfonylurea, thiazolidinedione, or insulin) to treat patients with T2D.
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Affiliation(s)
- Michaël J B van Baar
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Charlotte C van Ruiten
- 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
| | - Liselotte van Bloemendaal
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Richard G IJzerman
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Daniël H van Raalte
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands
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330
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Ronn J, Jensen EP, Wewer Albrechtsen NJ, Holst JJ, Sorensen CM. Glucagon-like peptide-1 acutely affects renal blood flow and urinary flow rate in spontaneously hypertensive rats despite significantly reduced renal expression of GLP-1 receptors. Physiol Rep 2018; 5. [PMID: 29233907 PMCID: PMC5727271 DOI: 10.14814/phy2.13503] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 10/17/2017] [Accepted: 10/19/2017] [Indexed: 02/06/2023] Open
Abstract
Glucagon‐like peptide‐1 (GLP‐1) is an incretin hormone increasing postprandial insulin release. GLP‐1 also induces diuresis and natriuresis in humans and rodents. The GLP‐1 receptor is extensively expressed in the renal vascular tree in normotensive rats where acute GLP‐1 treatment leads to increased mean arterial pressure (MAP) and increased renal blood flow (RBF). In hypertensive animal models, GLP‐1 has been reported both to increase and decrease MAP. The aim of this study was to examine expression of renal GLP‐1 receptors in spontaneously hypertensive rats (SHR) and to assess the effect of acute intrarenal infusion of GLP‐1. We hypothesized that GLP‐1 would increase diuresis and natriuresis and reduce MAP in SHR. Immunohistochemical staining and in situ hybridization for the GLP‐1 receptor were used to localize GLP‐1 receptors in the kidney. Sevoflurane‐anesthetized normotensive Sprague–Dawley rats and SHR received a 20 min intrarenal infusion of GLP‐1 and changes in MAP, RBF, heart rate, dieresis, and natriuresis were measured. The vasodilatory effect of GLP‐1 was assessed in isolated interlobar arteries from normo‐ and hypertensive rats. We found no expression of GLP‐1 receptors in the kidney from SHR. However, acute intrarenal infusion of GLP‐1 increased MAP, RBF, dieresis, and natriuresis without affecting heart rate in both rat strains. These results suggest that the acute renal effects of GLP‐1 in SHR are caused either by extrarenal GLP‐1 receptors activating other mechanisms (e.g., insulin) to induce the renal changes observed or possibly by an alternative renal GLP‐1 receptor.
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Affiliation(s)
- Jonas Ronn
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Elisa P Jensen
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,NNF Center for Basic Metabolic Research, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai J Wewer Albrechtsen
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,NNF Center for Basic Metabolic Research, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens Juul Holst
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,NNF Center for Basic Metabolic Research, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte M Sorensen
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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331
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Chen YC, Edinburgh RM, Hengist A, Smith HA, Walhin JP, Betts JA, Thompson D, Gonzalez JT. Venous blood provides lower glucagon-like peptide-1 concentrations than arterialized blood in the postprandial but not the fasted state: Consequences of sampling methods. Exp Physiol 2018; 103:1200-1205. [DOI: 10.1113/ep087118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/25/2018] [Indexed: 01/21/2023]
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332
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Hurren KM, Dunham MW. Understanding the impact of commonly utilized, non-insulin, glucose-lowering drugs on body weight in patients with type 2 diabetes. Expert Opin Pharmacother 2018; 19:1087-1095. [PMID: 29958007 DOI: 10.1080/14656566.2018.1494727] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The majority of patients with type 2 diabetes also have obesity. Obesity increases the risk of developing diabetes and is associated with worsened glycemic control and increased morbidity and mortality in individuals with diabetes. Sustained weight loss is associated with improved glycemic control, potential for diabetes remission, and decreased medical expenditures. AREAS COVERED Herein, the impact of commonly utilized, non-insulin, glucose-lowering drugs on body weight in patients with type 2 diabetes is discussed. The weight change magnitudes, mechanisms, and any within-class differences are also explored. EXPERT OPINION The weight impact of diabetes medications should be considered when designing treatment regimens, especially in patients who are overweight or have obesity. Lifestyle modification is paramount for optimal diabetes management. Therapeutic regimens should ideally be designed to maximize weight loss and at least minimize or avoid weight gain. Future glucose-lowering medications should continue to offer improvement in cardiovascular risk factors, including weight, in order to be accepted into the armamentarium of diabetes therapy. Therapeutic regimens should be designed to help patients with diabetes and obesity achieve both glycemic and weight goals. Management of these disease states is expected to become increasingly integrated.
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Affiliation(s)
- Kathryn M Hurren
- a Clinical Pharmacy Specialist, Department of Ambulatory Care , Veterans Affairs Ann Arbor Healthcare System , Ann Arbor , MI , USA
| | - Marissa W Dunham
- a Clinical Pharmacy Specialist, Department of Ambulatory Care , Veterans Affairs Ann Arbor Healthcare System , Ann Arbor , MI , USA
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333
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Packer M. Is the Popularity of Dipeptidyl-Peptidase-4 Inhibitors Justified? Insights From Mechanistic Studies and Clinical Trials. Am J Med 2018; 131:e287-e289. [PMID: 29307538 DOI: 10.1016/j.amjmed.2017.11.055] [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: 11/23/2017] [Revised: 11/28/2017] [Accepted: 11/28/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas.
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334
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Rayner CK, Horowitz M. Agonism of receptors in the gut-pancreas axis in type 2 diabetes: are two better than one? Lancet 2018; 391:2577-2578. [PMID: 29945728 DOI: 10.1016/s0140-6736(18)30936-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 04/16/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Christopher K Rayner
- Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide 5000, SA, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Michael Horowitz
- Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide 5000, SA, Australia; Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia.
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335
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Tanaka A, Node K. Clinical application of glucagon-like peptide-1 receptor agonists in cardiovascular disease: lessons from recent clinical cardiovascular outcomes trials. Cardiovasc Diabetol 2018; 17:85. [PMID: 29895290 PMCID: PMC5996475 DOI: 10.1186/s12933-018-0731-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 06/06/2018] [Indexed: 12/30/2022] Open
Abstract
Recent clinical trials investigating cardiovascular (CV) safety of newer antidiabetic agents have been rapidly and largely changing the landscape of diabetes care and providing highly important clinical information on decision-making regarding the choice of antidiabetic agents. Similar to the sodium-glucose cotransporter 2 (SGLT2) inhibitors, some glucagon-like peptide-1 receptor agonists (GLP-1RAs) have also demonstrated a marked risk reduction in major adverse CV events (MACE) in patients with type 2 diabetes at high risk of CV events. However, the two classes of agents differ largely in their pharmacological modes of action on glucose-lowering and CV parameters. Furthermore, CV benefits on individual components of MACE and other outcomes, including heart failure (HF), appear to differ partly between the two classes. Specifically, improvement of overall CV outcomes was likely driven by reduction in HF-related events in trials investigating SGLT2 inhibitors, and by reduction in atherosclerotic events in those investigating GLP-1RAs. This difference in CV benefit observed in the trials has important clinical implications regarding how to use the two classes of agents and how to identify suitable patients to obtain the best benefit from each class during routine diabetes care, possibly leading to a treatment plan tailored to an individual patient’s CV risk and clinical condition. At this stage, however, we cardiologists may overlook such differences and may be unfamiliar with GLP-1RAs specifically. Herein, we highlight the potential benefits of GLP-1RAs on CV parameters observed in recent CV outcomes trials and further discuss clinical application of GLP-1RAs in CV medicine.
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Affiliation(s)
- Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
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336
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GLP-1 receptor agonists and cardiovascular protection: A class effect or not? DIABETES & METABOLISM 2018; 44:193-196. [DOI: 10.1016/j.diabet.2017.12.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 12/17/2017] [Indexed: 01/22/2023]
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Ibrahim MA, Geddawy A, Abdel-Wahab S. Sitagliptin prevents isoproterenol-induced myocardial infarction in rats by modulating nitric oxide synthase enzymes. Eur J Pharmacol 2018; 829:63-69. [DOI: 10.1016/j.ejphar.2018.04.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 04/04/2018] [Accepted: 04/09/2018] [Indexed: 02/04/2023]
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Bailey CJ, Day C. Treatment of type 2 diabetes: future approaches. Br Med Bull 2018; 126:123-137. [PMID: 29897499 DOI: 10.1093/brimed/ldy013] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 03/26/2018] [Indexed: 01/13/2023]
Abstract
INTRODUCTION OR BACKGROUND Type 2 diabetes, which accounts for ~90% of all diabetes, is a heterogeneous and progressive disease with a variety of causative and potentiating factors. The hyperglycaemia of type 2 diabetes is often inadequately controlled, hence the need for a wider selection of glucose-lowering treatments. SOURCES OF DATA Medline, PubMed, Web of Science and Google Scholar. AREAS OF AGREEMENT Early, effective and sustained control of blood glucose defers the onset and reduces the severity of microvascular and neuropathic complications of type 2 diabetes and helps to reduce the risk of cardiovascular (CV) complications. AREAS OF CONTROVERSY Newer glucose-lowering agents require extensive long-term studies to confirm CV safety. The positioning of newer agents within therapeutic algorithms varies. GROWING POINTS In addition to their glucose-lowering efficacy, some new glucose-lowering agents may act independently to reduce CV and renal complications. AREAS TIMELY FOR DEVELOPING RESEARCH Studies of potential new glucose-lowering agents offer the opportunity to safely improve glycaemic control with prolonged efficacy and greater opportunity for therapeutic individualisation.
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Affiliation(s)
- Clifford J Bailey
- Department of Biomedical Sciences, School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Caroline Day
- Department of Biomedical Sciences, School of Life and Health Sciences, Aston University, Birmingham, UK
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339
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Munir KM, Davis SN. Are SGLT2 inhibitors or GLP-1 receptor agonists more appropriate as a second-line therapy in type 2 diabetes? Expert Opin Pharmacother 2018; 19:773-777. [DOI: 10.1080/14656566.2018.1475559] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Kashif M. Munir
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Center for Diabetes and Endocrinology, Baltimore, MD, USA
| | - Stephen N. Davis
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Chiazza F, Tammen H, Pintana H, Lietzau G, Collino M, Nyström T, Klein T, Darsalia V, Patrone C. The effect of DPP-4 inhibition to improve functional outcome after stroke is mediated by the SDF-1α/CXCR4 pathway. Cardiovasc Diabetol 2018; 17:60. [PMID: 29776406 PMCID: PMC5960142 DOI: 10.1186/s12933-018-0702-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/05/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Dipeptidyl peptidase-4 (DPP-4) inhibitors (gliptins) are approved drugs for the treatment of hyperglycemia in patients with type 2 diabetes. These effects are mainly mediated by inhibiting endogenous glucagon-like peptide-1 (GLP-1) cleavage. Interestingly, gliptins can also improve stroke outcome in rodents independently from GLP1. However, the underlying mechanisms are unknown. Stromal cell-derived factor-1α (SDF-1α) is a DPP-4 substrate and CXCR4 agonist promoting beneficial effects in injured brains. However, SDF-1α involvement in gliptin-mediated neuroprotection after ischemic injury is unproven. We aimed to determine whether the gliptin linagliptin improves stroke outcome via the SDF-1α/CXCR4 pathway, and identify additional effectors behind the efficacy. METHODS Mice were subjected to stroke by transient middle cerebral artery occlusion (MCAO). linagliptin was administered for 3 days or 3 weeks from stroke onset. The CXCR4-antagonist AMD3100 was administered 1 day before MCAO until 3 days thereafter. Stroke outcome was assessed by measuring upper-limb function, infarct volume and neuronal survival. The plasma and brain levels of active GLP-1, GIP and SDF-1α were quantified by ELISA. To identify additional gliptin-mediated molecular effectors, brain samples were analyzed by mass spectrometry. RESULTS Linagliptin specifically increased active SDF-1α but not glucose-dependent insulinotropic peptide (GIP) or GLP-1 brain levels. Blocking of SDF-1α/CXCR4 pathway abolished the positive effects of linagliptin on upper-limb function and histological outcome after stroke. Moreover, linagliptin treatment after stroke decreased the presence of peptides derived from neurogranin and from an isoform of the myelin basic protein. CONCLUSIONS We showed that linagliptin improves functional stroke outcome in a SDF-1α/CXCR4-dependent manner. Considering that Calpain activity and intracellular Ca2+ regulate neurogranin and myelin basic protein detection, our data suggest a gliptin-mediated neuroprotective mechanism via the SDF-1α/CXCR4 pathway that could involve the regulation of Ca2+ homeostasis and the reduction of Calpain activity. These results provide new insights into restorative gliptin-mediated effects against stroke.
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Affiliation(s)
- Fausto Chiazza
- Department of Clinical Science and Education, Södersjukhuset, Internal Medicine, Karolinska Institutet, 118 83, Stockholm, Sweden.
| | | | - Hiranya Pintana
- Department of Clinical Science and Education, Södersjukhuset, Internal Medicine, Karolinska Institutet, 118 83, Stockholm, Sweden
| | - Grazyna Lietzau
- Department of Clinical Science and Education, Södersjukhuset, Internal Medicine, Karolinska Institutet, 118 83, Stockholm, Sweden
| | - Massimo Collino
- Department of Drug Science and Technology, University of Turin, Torino, Italy
| | - Thomas Nyström
- Department of Clinical Science and Education, Södersjukhuset, Internal Medicine, Karolinska Institutet, 118 83, Stockholm, Sweden
| | - Thomas Klein
- Department of CardioMetabolic Diseases Research, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Vladimer Darsalia
- Department of Clinical Science and Education, Södersjukhuset, Internal Medicine, Karolinska Institutet, 118 83, Stockholm, Sweden.
| | - Cesare Patrone
- Department of Clinical Science and Education, Södersjukhuset, Internal Medicine, Karolinska Institutet, 118 83, Stockholm, Sweden.
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GLP-1 receptor agonists and reduction of cardiometabolic risk: Potential underlying mechanisms. Biochim Biophys Acta Mol Basis Dis 2018; 1864:2814-2821. [PMID: 29778663 DOI: 10.1016/j.bbadis.2018.05.012] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus (T2DM) is a metabolic condition with an elevated impact on cardiovascular (CV) risk. The innovative therapeutic approaches for T2DM - incretin-based therapies (IBTs), including glucagon-like peptide 1 (GLP-1) receptor agonists, have become popular and more widely used in recent years. The available scientific data from clinical studies and clinical practice highlights their beyond glucose-lowering effects, which is achieved without any increase in hypoglycaemia. The former effects include reduction in body weight, lipids, blood pressure, inflammatory markers, oxidative stress, endothelial dysfunction, and subclinical atherosclerosis, thus reducing and potentially preventing CV events. In fact, the introduction of IBTs is one of the key moments in the history of diabetes research and treatment. Such therapeutic strategies allow customization of antidiabetic treatment to each patient's need and therefore obtain better metabolic control with reduced CV risk. The aim of the present paper is to provide a comprehensive overview of the effects of GLP-1RA on various cardiometabolic markers and overall CV risk, with particular attention on recent CV outcome studies and potential mechanisms. In particular, the effects of liraglutide on formation and progression of atherosclerotic plaque and mechanisms explaining its cardioprotective effects are highlighted.
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342
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Abstract
Cardiovascular disease (CVD) is a major challenge in the management of type 2 diabetes mellitus. Glucose-lowering agents that reduce the risk of major cardiovascular events would be considered a major advance, as recently reported with liraglutide and semaglutide, 2 glucagon-like peptide-1 receptor agonists, and with empagliflozin and canagliflozin, 2 SGLT-2 (sodium-glucose cotransporter type 2) inhibitors, but not with DPP-4 (dipeptidyl peptidase-4) inhibitors. The present review is devoted to CV effects of new oral glucose-lowering agents. DPP-4 inhibitors (gliptins) showed some positive cardiac and vascular effects in preliminary studies, and initial data from phase 2 to 3 clinical trials suggested a reduction in major cardiovascular events. However, subsequent CV outcome trials with alogliptin, saxagliptin, and sitagliptin showed noninferiority but failed to demonstrate any superiority compared with placebo in patients with type 2 diabetes mellitus and high CV risk. An unexpected higher risk of hospitalization for heart failure was reported with saxagliptin. SGLT-2 inhibitors (gliflozins) promote glucosuria, thus reducing glucose toxicity and body weight, and enhance natriuresis, thus lowering blood pressure. Two CV outcome trials in type 2 diabetes mellitus patients mainly in secondary prevention showed remarkable positive results. Empagliflozin in EMPA-REG-OUTCOME (EMPAgliflozin Cardiovascular OUTCOME Events in Type 2 Diabetes Mellitus Patients) reduced major cardiovascular events, CV mortality, all-cause mortality, and hospitalization for heart failure. In CANVAS (Canagliflozin Cardiovascular Assessment Study), the reduction in CV mortality with canagliflozin failed to reach statistical significance despite a similar reduction in major cardiovascular events. The underlying protective mechanisms of SGLT-2 inhibitors remain unknown and both hemodynamic and metabolic explanations have been proposed. CVD-REAL studies (Comparative Effectiveness of Cardiovascular Outcomes in New Users of Sodium-Glucose Cotransporter-2 Inhibitors; with the limitation of an observational approach) suggested that these favorable results may be considered as a class effect shared by all SGLT-2 inhibitors (including dapagliflozin) and be extrapolated to a larger population of patients with type 2 diabetes mellitus in primary prevention. Ongoing CV outcome trials with other DPP-4 (linagliptin) and SGLT-2 (dapagliflozin, ertugliflozin) inhibitors should provide additional information about CV effects of both pharmacological classes.
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Affiliation(s)
- André J Scheen
- From the Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Belgium (A.J.S.)
- Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Belgium (A.J.S.)
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343
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Aroor AR, Manrique-Acevedo C, DeMarco VG. The role of dipeptidylpeptidase-4 inhibitors in management of cardiovascular disease in diabetes; focus on linagliptin. Cardiovasc Diabetol 2018; 17:59. [PMID: 29669555 PMCID: PMC5907287 DOI: 10.1186/s12933-018-0704-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/12/2018] [Indexed: 12/15/2022] Open
Abstract
Multiple population based analyses have demonstrated a high incidence of cardiovascular disease (CVD) and cardiovascular (CV) mortality in subjects with T2DM that reduces life expectancy by as much as 15 years. Importantly, the CV system is particularly sensitive to the metabolic and immune derangements present in obese pre-diabetic and diabetic individuals; consequently, CV dysfunction is often the initial CV derangement to occur and promotes the progression to end organ/tissue damage in T2DM. Specifically, diabetic CVD can manifest as microvascular complications, such as nephropathy, retinopathy, and neuropathy, as well as, macrovascular impairments, including ischemic heart disease, peripheral vascular disease, and cerebrovascular disease. Despite some progress in prevention and treatment of CVD, mainly via blood pressure and dyslipidemia control strategies, the impact of metabolic disease on CV outcomes is still a major challenge and persists in proportion to the epidemics of obesity and diabetes. There is abundant pre-clinical and clinical evidence implicating the DPP-4-incretin axis in CVD. In this regard, linagliptin is a unique DPP-4 inhibitor with both CV and renal safety profiles. Moreover, it exerts beneficial CV effects beyond glycemic control and beyond class effects. Linagliptin is protective for both macrovascular and microvascular complications of diabetes in preclinical models, as well as clinical models. Given the role of endothelial-immune cell interactions as one of the key events in the initiation and progression of CVD, linagliptin modulates these cell–cell interactions by affecting two important pathways involving stimulation of NO signaling and potent inhibition of a key immunoregulatory molecule.
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Affiliation(s)
- Annayya R Aroor
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO, USA.,Division of Endocrinology and Metabolism, Department of Medicine, University of Missouri-Columbia School of Medicine, One Hospital Drive, Columbia, MO, 65212, USA.,Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA
| | - Camila Manrique-Acevedo
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO, USA.,Division of Endocrinology and Metabolism, Department of Medicine, University of Missouri-Columbia School of Medicine, One Hospital Drive, Columbia, MO, 65212, USA.,Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA
| | - Vincent G DeMarco
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO, USA. .,Division of Endocrinology and Metabolism, Department of Medicine, University of Missouri-Columbia School of Medicine, One Hospital Drive, Columbia, MO, 65212, USA. .,Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA. .,Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, MO, USA.
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344
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Zheng SL, Roddick AJ, Aghar-Jaffar R, Shun-Shin MJ, Francis D, Oliver N, Meeran K. Association Between Use of Sodium-Glucose Cotransporter 2 Inhibitors, Glucagon-like Peptide 1 Agonists, and Dipeptidyl Peptidase 4 Inhibitors With All-Cause Mortality in Patients With Type 2 Diabetes: A Systematic Review and Meta-analysis. JAMA 2018; 319:1580-1591. [PMID: 29677303 PMCID: PMC5933330 DOI: 10.1001/jama.2018.3024] [Citation(s) in RCA: 257] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE The comparative clinical efficacy of sodium-glucose cotransporter 2 (SGLT-2) inhibitors, glucagon-like peptide 1 (GLP-1) agonists, and dipeptidyl peptidase 4 (DPP-4) inhibitors for treatment of type 2 diabetes is unknown. OBJECTIVE To compare the efficacies of SGLT-2 inhibitors, GLP-1 agonists, and DPP-4 inhibitors on mortality and cardiovascular end points using network meta-analysis. DATA SOURCES MEDLINE, Embase, Cochrane Library Central Register of Controlled Trials, and published meta-analyses from inception through October 11, 2017. STUDY SELECTION Randomized clinical trials enrolling participants with type 2 diabetes and a follow-up of at least 12 weeks were included, for which SGLT-2 inhibitors, GLP-1 agonists, and DPP-4 inhibitors were compared with either each other or placebo or no treatment. DATA EXTRACTION AND SYNTHESIS Data were screened by 1 investigator and extracted in duplicate by 2 investigators. A Bayesian hierarchical network meta-analysis was performed. MAIN OUTCOMES AND MEASURES The primary outcome: all-cause mortality; secondary outcomes: cardiovascular (CV) mortality, heart failure (HF) events, myocardial infarction (MI), unstable angina, and stroke; safety end points: adverse events and hypoglycemia. RESULTS This network meta-analysis of 236 trials randomizing 176 310 participants found SGLT-2 inhibitors (absolute risk difference [RD], -1.0%; hazard ratio [HR], 0.80 [95% credible interval {CrI}, 0.71 to 0.89]) and GLP-1 agonists (absolute RD, -0.6%; HR, 0.88 [95% CrI, 0.81 to 0.94]) were associated with significantly lower all-cause mortality than the control groups. SGLT-2 inhibitors (absolute RD, -0.9%; HR, 0.78 [95% CrI, 0.68 to 0.90]) and GLP-1 agonists (absolute RD, -0.5%; HR, 0.86 [95% CrI, 0.77 to 0.96]) were associated with lower mortality than were DPP-4 inhibitors. DPP-4 inhibitors were not significantly associated with lower all-cause mortality (absolute RD, 0.1%; HR, 1.02 [95% CrI, 0.94 to 1.11]) than were the control groups. SGLT-2 inhibitors (absolute RD, -0.8%; HR, 0.79 [95% CrI, 0.69 to 0.91]) and GLP-1 agonists (absolute RD, -0.5%; HR, 0.85 [95% CrI, 0.77 to 0.94]) were significantly associated with lower CV mortality than were the control groups. SGLT-2 inhibitors were significantly associated with lower rates of HF events (absolute RD, -1.1%; HR, 0.62 [95% CrI, 0.54 to 0.72]) and MI (absolute RD, -0.6%; HR, 0.86 [95% CrI, 0.77 to 0.97]) than were the control groups. GLP-1 agonists were associated with a higher risk of adverse events leading to trial withdrawal than were SGLT-2 inhibitors (absolute RD, 5.8%; HR, 1.80 [95% CrI, 1.44 to 2.25]) and DPP-4 inhibitors (absolute RD, 3.1%; HR, 1.93 [95% CrI, 1.59 to 2.35]). CONCLUSIONS AND RELEVANCE In this network meta-analysis, the use of SGLT-2 inhibitors or GLP-1 agonists was associated with lower mortality than DPP-4 inhibitors or placebo or no treatment. Use of DPP-4 inhibitors was not associated with lower mortality than placebo or no treatment.
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Affiliation(s)
- Sean L. Zheng
- Department of Endocrinology, Imperial College Healthcare NHS Foundation Trust, London, United Kingdom
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
- Imperial College London, United Kingdom
| | - Alistair J. Roddick
- Faculty of Life Sciences and Medicine, King’s College London, United Kingdom
| | - Rochan Aghar-Jaffar
- Department of Endocrinology, Imperial College Healthcare NHS Foundation Trust, London, United Kingdom
- Imperial College London, United Kingdom
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, United Kingdom
| | | | | | - Nick Oliver
- Department of Endocrinology, Imperial College Healthcare NHS Foundation Trust, London, United Kingdom
- Imperial College London, United Kingdom
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, United Kingdom
| | - Karim Meeran
- Department of Endocrinology, Imperial College Healthcare NHS Foundation Trust, London, United Kingdom
- Imperial College London, United Kingdom
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, United Kingdom
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345
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Thomson SC, Vallon V. Renal Effects of Incretin-Based Diabetes Therapies: Pre-clinical Predictions and Clinical Trial Outcomes. Curr Diab Rep 2018; 18:28. [PMID: 29654381 PMCID: PMC6426321 DOI: 10.1007/s11892-018-0991-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to correlate predictions based on pre-clinical data with outcomes from clinical trials that examine the effects of incretin-based diabetes treatments on the kidney. The incretin-based treatments include agonists of the glucagon-like peptide 1 receptor (GLP-1R) and inhibitors of the enzyme, dipeptidyl peptidase-4 (DPP-4). In addition, what is known about the incretin-based therapies will be compared to what is known about the renal effects of SGLT2 inhibitors. RECENT FINDINGS Large-scale clinical trials have shown that SGLT2 inhibitors reduce albuminuria and preserve estimated glomerular filtration rate (eGFR) in patients with diabetic nephropathy. A concise and plausible hemodynamic mechanism is supported by pre-clinical research on the physiology and pharmacology of SGLT2. Large-scale clinical trials have shown that incretin-based therapies mitigate albuminuria but have not shown beneficial effects on eGFR. Research on the incretin-based therapies has yielded a diverse array of direct effects throughout the body, which fuels speculation as to how these drugs might benefit the diabetic kidney and affect its function(s). But in vivo experiments have yet to confirm that the proposed mechanisms underlying emergent phenomena, such as proximal tubular fluid reabsorption, are the ones predicted by cell and molecular experiments. There may be salutary effects of incretin-based treatments on the diabetic kidney, but the system is complex and not amenable to simple explanation or prior prediction. This contrasts with the renal effects of SGLT2 inhibitors, which can be explained concisely.
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Affiliation(s)
- Scott C Thomson
- University of California, 3350 La Jolla Village Drive 9151, San Diego, CA, 92161, USA.
- VA San Diego Healthcare System, San Diego, USA.
| | - Volker Vallon
- University of California, 3350 La Jolla Village Drive 9151, San Diego, CA, 92161, USA
- VA San Diego Healthcare System, San Diego, USA
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346
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Mulvihill EE. Regulation of intestinal lipid and lipoprotein metabolism by the proglucagon-derived peptides glucagon like peptide 1 and glucagon like peptide 2. Curr Opin Lipidol 2018; 29:95-103. [PMID: 29432213 PMCID: PMC5882252 DOI: 10.1097/mol.0000000000000495] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW The intestine is highly efficient at absorbing and packaging dietary lipids onto the structural protein apoB48 for distribution throughout the body. Here, we summarize recent advances into understanding the physiological and pharmacological actions of the proglucagon-derived peptides: glucagon like peptide 1 (GLP-1) and glucagon like peptide 2 (GLP-2) on intestinal lipoprotein secretion. RECENT FINDINGS Several recent studies have elucidated mechanisms underlying the paradoxical effects of GLP-1 and GLP-2 on intestinal production of triglyceride-rich lipoproteins (TRLs). Both gut-derived peptides are secreted on an equimolar basis in response to the same nutrient stimulus. Despite neither receptor demonstrating clear localization to enterocytes, a single injection of a GLP-1R agonist rapidly decreases delivery of intestinally packaged fatty acids into the plasma, while conversely GLP-2 receptor (GLP-2R) activation acutely increases TRL concentrations in plasma. SUMMARY The regulation of TRL secretion is dependent on the coordination of many processes: fatty acid availability uptake, assembly onto the apoB48 polypeptide backbone, secretion and reuptake, which the hormonal, neural, inflammatory and metabolic milieu can all strongly influence. Understanding of how GLP-1 and GLP-2 receptor agonists control TRL production has clinical importance given that GLP1R agonists were recently demonstrated not only to provide glycemic control but also to prevent major adverse cardiovascular events in patients with T2DM and the success of GLP-2R agonists in treating short bowel disease.
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Affiliation(s)
- Erin E Mulvihill
- University of Ottawa Heart Institute, University of Ottawa, Department of Biochemistry, Microbiology and Immunology, Ottawa, Ontario, Canada
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Lim S, Kim KM, Nauck MA. Glucagon-like Peptide-1 Receptor Agonists and Cardiovascular Events: Class Effects versus Individual Patterns. Trends Endocrinol Metab 2018; 29:238-248. [PMID: 29463450 DOI: 10.1016/j.tem.2018.01.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/28/2018] [Accepted: 01/29/2018] [Indexed: 02/06/2023]
Abstract
Several new glucose-lowering medications have been approved, such as dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs), and sodium glucose cotransporter-2 inhibitors. Among GLP-1RAs, lixisenatide, a short-acting drug, did not show cardiovascular (CV) benefits in patients with Type 2 diabetes mellitus (T2D) and acute coronary syndrome. Extended-release exenatide was also not significantly better for CV outcomes. By contrast, once daily liraglutide and once weekly semaglutide, both long-acting GLP-1RAs, decreased the incidence of major adverse CV events and mortality. This Review attempts to explain favorable CV results with some, but not all, GLP-1RAs, to aid in their differential prescription with the aim of further reducing the adverse CV burden of T2D.
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Affiliation(s)
- Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Kyoung Min Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Michael A Nauck
- Diabetes Center Bochum-Hattingen, Department of Medicine I, St Josef-Hospital (Ruhr-Universität Bochum), Bochum, Germany.
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348
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Jendle J, Fang X, Cao Y, Bojö L, Nilsson BK, Hedberg F, Santos-Pardo I, Nyström T. Effects on repetitive 24-hour ambulatory blood pressure in subjects with type II diabetes randomized to liraglutide or glimepiride treatment both in combination with metformin: a randomized open parallel-group study. ACTA ACUST UNITED AC 2018; 12:346-355. [PMID: 29548934 DOI: 10.1016/j.jash.2018.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/02/2018] [Accepted: 02/08/2018] [Indexed: 12/22/2022]
Abstract
In this post hoc study, we aimed to investigate liraglutide treatment on repetitive 24-hour blood pressure (BP) in patients with type II diabetes. Sixty-two individuals with type II diabetes (45 males) were randomized to 1.8 mg liraglutide once daily or 4 mg glimepiride together with 1 g metformin twice daily. Ambulatory 24-hour systolic and diastolic blood pressure (sBP/dBP) was repetitively measured at baseline, 2 weeks, and 18 weeks. Outcomes were evaluated as treatment change from baseline, 2 weeks, and 18 weeks. Baseline clinical characteristics of liraglutide (n = 33) and glimepiride (n = 29) groups were well matched. No statistically significant difference in 24-hour sBP/dBP between three time periods and groups was observed. There was no treatment change for 24-hour sBP at week 2 or after week 18. There was a transient treatment change in 24-hour dBP in the liraglutide group at week 2 (3.2 ± 5.4 vs. -1.2 ± 4.5 mm Hg, P < .01). A treatment change in 24-hour heart rate at week 2 (4.9 ± 6.8 vs. 1.0 ± 6.0 bpm, P = .03) and at week 18 (5.9 ± 7.8 vs. 0.2 ± 6.3 bpm, P < .01) was observed in the liraglutide group. In conclusion, liraglutide treatment did not lower BP. However, a small diurnal variation in dBP without affecting BP variability or nocturnal BP dipping was observed.
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Affiliation(s)
- Johan Jendle
- Institution of Medical Sciences, Örebro University, Örebro, Sweden.
| | - Xin Fang
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Yang Cao
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | | | | | - Fredric Hedberg
- Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden
| | - Irene Santos-Pardo
- Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden
| | - Thomas Nyström
- Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden
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349
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Worsening Heart Failure During the Use of DPP-4 Inhibitors: Pathophysiological Mechanisms, Clinical Risks, and Potential Influence of Concomitant Antidiabetic Medications. JACC-HEART FAILURE 2018. [PMID: 29525332 DOI: 10.1016/j.jchf.2017.12.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Although dipeptidyl peptidase (DPP)-4 inhibitors have been reported to have a neutral effect on thromboembolic vaso-occlusive events in large-scale trials, they act to potentiate several endogenous peptides that can exert deleterious cardiovascular effects. Experimentally, DPP-4 inhibitors may augment the ability of glucagon-like peptide-1 to stimulate cyclic adenosine monophosphate in cardiomyocytes, and potentiation of the effects of stromal cell-derived factor-1 by DPP-4 inhibitors may aggravate cardiac fibrosis. These potentially deleterious actions of DPP-4 inhibitors might not become clinically apparent if these drugs were to promote sodium excretion. However, the natriuretic effect of DPP-4 inhibitors is modest, because they act on the distal (rather than proximal) renal tubules. Accordingly, both clinical trials and observational studies have reported an increase in the risk of heart failure in patients with type 2 diabetes who were receiving DPP-4 inhibitors. This risk may be muted in trials with a high prevalence of metformin use or with low and declining background use of insulin and thiazolidinediones. Still, the most vulnerable patients (i.e., those with established heart failure) were not well represented in these studies. The only trial that specifically evaluated patients with pre-existing left ventricular dysfunction observed important drug-related adverse structural and clinical effects. In conclusion, an increased risk of worsening heart failure appears to be a class effect of DPP-4 inhibitors, even in patients without a history of heart failure. Additional clinical trials are urgently needed to elucidate the benefits and risks of DPP-4 inhibitors in patients with established left ventricular dysfunction.
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Abstract
INTRODUCTION Dipeptidyl peptidase-4 inhibitors (DPP-4is) are generally considered as glucose-lowering agents with a safe profile in type 2 diabetes. AREAS COVERED An updated review of recent safety data from randomised controlled trials, observational studies, meta-analyses, pharmacovigilance reports regarding alogliptin, linagliptin, saxagliptin, sitagliptin, and vildagliptin, with a special focus on risks of hypoglycemia, pancreatitis and pancreatic cancer, major cardiovascular events, hospitalisation for heart failure and other new safety issues, such as bone fractures and arthralgia. The safety of DPP-4i use in special populations, elderly patients, patients with renal impairment, liver disease or heart failure, will also be discussed. EXPERT OPINION The good tolerance/safety profile of DPP-4is has been largely confirmed, including in more fragile populations, with no gastrointestinal adverse effects and a minimal risk of hypoglycemia. DPP-4is appear to be associated with a small increased incidence of acute pancreatitis in placebo-controlled trials, although most observational studies are reassuring. Most recent studies with DPP-4is do not confirm the increased risk of hospitalisation for heart failure reported with saxagliptin in SAVOR-TIMI 53, but further post-marketing surveillance is still recommended. New adverse events have been reported such as arthralgia, yet a causal relationship remains unclear.
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Affiliation(s)
- André Jacques Scheen
- a Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine , CHU Sart Tilman, University of Liège , Liège , Belgium.,b Division of Clinical Pharmacology , Center for Interdisciplinary Research on Medicines (CIRM) , Liège , Belgium
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