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Scheen AJ. Underuse of GLP-1 receptor agonists in the management of type 2 diabetes despite a favorable benefit-safety profile. Expert Opin Drug Saf 2024; 23:797-810. [PMID: 38738549 DOI: 10.1080/14740338.2024.2354885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 05/09/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Patients with type 2 diabetes (T2DM) are at high risk of atherosclerotic cardiovascular disease (ASCVD) and cardiovascular death. Cardiovascular protection is a key objective in T2DM. AREAS COVERED Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have proven their efficacy in reducing major cardiovascular events in high-risk patients with T2DM in placebo-controlled trials, a finding confirmed in observational studies compared with other glucose-lowering agents. Overall, GLP-1RAs have a good safety profile associated with a favorable benefit/risk ratio for the management of T2DM, even if their cost-effectiveness might be questionable. International guidelines recommend GLP-1RAs as preferred glucose-lowering agents in patients with ASCVD and as a valuable alternative in overweight/obese patients with T2DM. However, real-life studies worldwide revealed that only a minority of patients receive a GLP-1RA, despite a positive trend for increased prescriptions in recent years. Surprisingly, however, fewer patients with established ASCVD are treated with these cardioprotective antihyperglycemic agents versus patients without ASCVD. EXPERT OPINION The reasons for GLP-1RA underuse in clinical practice are multiple. Multifaceted and coordinated interventions targeting all actors of the health-care system must be implemented to stimulate the adoption of GLP-1RAs as part of routine cardiovascular care among patients with T2DM, especially in those with ASCVD.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, CHU Liège, Liège, Belgium
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium
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Bonora BM, Russo G, Leonetti F, Strazzabosco M, Nollino L, Aimaretti G, Giaccari A, Broglio F, Consoli A, Avogaro A, Fadini GP. Effectiveness of oral semaglutide on glucose control and body weight up to 18 months: a multicenter retrospective real-world study. J Endocrinol Invest 2024; 47:1395-1403. [PMID: 38369592 PMCID: PMC11142994 DOI: 10.1007/s40618-024-02309-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/11/2024] [Indexed: 02/20/2024]
Abstract
AIM Oral semaglutide, an innovative orally administered GLP-1 receptor agonist for type 2 diabetes (T2D) management was herein evaluated for its effectiveness in a multi-center retrospective real-world study. METHODS We included new-users of oral semaglutide from 18 specialist care centres and collected retrospective data on baseline clinical characteristics. Updated values of HbA1c and body weight were analyzed using the mixed model for repeated measures. RESULTS The study included 166 individuals with T2D, predominantly men (64.5%), with a mean age of 64.4 years and a mean diabetes duration of 10.1 years. In the majority of patients (68.3%) oral semaglutide was used as a second-line drug, mostly with metformin. At baseline, mean BMI was 28.9 kg/m2 and HbA1c was 7.5%. During the 18-month observation period, oral semaglutide demonstrated significant reductions in HbA1c, with a maximum change of - 0.9%, and 42.1% of patients achieved HbA1c values below 7.0%. Additionally, there was a substantial reduction in body weight, with an estimated change of - 3.4 kg at 18 months, and 30.3% of patients experienced a 5% or greater reduction in baseline body weight. Only 24.2% of patients reached the 14 mg dose. Subgroup analysis revealed that baseline HbA1c > 7%, persistence on drug, not being on a prior therapy with DPP-4 inhibitors, and loosing 5% or more the initial body weight were associated with greater HbA1c reductions. CONCLUSION This study supports oral semaglutide as an effective option for T2D treatment, offering improved glucose control and weight management in a real-world setting.
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Affiliation(s)
- B M Bonora
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
| | - G Russo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - F Leonetti
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - M Strazzabosco
- Diabetology and Metabolic Diseases Unit, S. Bortolo Hospital, Vicenza, Italy
| | - L Nollino
- Department of Medicine, Diabetology Service, Azienda ULSS 2 Marca Trevigiana, Treviso, Italy
| | - G Aimaretti
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - A Giaccari
- Centro per le Malattie Endocrine e Metaboliche, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - F Broglio
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - A Consoli
- Endocrinology and Metabolism Unit, ASL, Pescara, Italy
- Department of Medicine and Aging Sciences DMSI and Center for Advanced Studies and Technology CAST, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - A Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - G P Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
- Veneto Institute of Molecular Medicine, Padua, Italy.
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Fadini GP, Bonora BM, Ghiani M, Anichini R, Melchionda E, Fattor B, Fazion S, Meregalli G, Giaccari A, Avogaro A, Consoli A. Oral or injectable semaglutide for the management of type 2 diabetes in routine care: A multicentre observational study comparing matched cohorts. Diabetes Obes Metab 2024; 26:2390-2400. [PMID: 38477183 DOI: 10.1111/dom.15554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/24/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024]
Abstract
AIM To investigate the real-world utilization and comparative clinical outcomes of injectable and oral semaglutide in individuals with type 2 diabetes (T2D) with the aim of enhancing understanding of the practical implications associated with choosing between these formulations. METHODS New users of oral or injectable semaglutide were selected from a cohort of 14 079 initiators of glucagon-like peptide-1 receptor agonists. Propensity-score matching (PSM) was employed to create balanced groups, ensuring comparability. The analysis encompassed dose exposure, drug persistence, and clinical outcomes, including changes in glycated haemoglobin (HbA1c) and body weight, with up to 18 months' follow-up. RESULTS We analysed two matched groups of 107 participants each, who comprised on average 63.6% men, aged 64 years, with diabetes duration of approximately 10 years, body mass index of 29 kg/m2 and HbA1c level of 7.7-7.8% (61-62 mmol/mol). The proportion of low, intermediate and high doses were similar with the oral and the injectable formulation. The change in HbA1c was similar between groups (-0.9% / -10 mmol/mol at 18 months) as was the proportion of individuals reaching HbA1c <6.5% (48 mmol/mol). The average change in body weight was similar in the two groups (-3.7 kg with injectable and -3.3 kg with oral at 18 months) but more new users of injectable semaglutide lost ≥5% body weight. Persistence on drug was longer with injectable than with oral semaglutide. CONCLUSION In a real-world setting, improvements in HbA1c and body weight were similar after initiation of oral or injectable semaglutide. These results may be specific to the features of the matched cohorts under investigation, with limited generalizability to populations with different characteristics.
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Affiliation(s)
- Gian Paolo Fadini
- Department of Medicine, University of Padova, Padua, Italy
- Veneto Institute of Molecular Medicine (VIMM), Padua, Italy
| | - Benedetta Maria Bonora
- Department of Medicine, University of Padova, Padua, Italy
- Veneto Institute of Molecular Medicine (VIMM), Padua, Italy
| | - Mariangela Ghiani
- Diabetology Unit, Azienda Sanitaria Locale 8 Cagliari Quartu S. Elena, Cagliari, Italy
| | - Roberto Anichini
- Diabetes Unit Area Pistoiese, USL Centro Toscana, Pistoia, Italy
| | - Elena Melchionda
- Diabetology and Metabolic Diseases, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Bruno Fattor
- Diabetology Service, Azienda Sanitaria dell'Alto Adige, Bolzano, Italy
| | - Stefano Fazion
- Diabetology and Metabolic Diseases, Ospedale C. Poma, Mantova, Italy
| | - Giancarla Meregalli
- Endocrine Disease Center and Regional Diabetes Center, ASST, Bergamo Ovest, Italy
| | - Andrea Giaccari
- Endocrine and Metabolic Center, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padua, Italy
| | - Agostino Consoli
- Endocrinology and Metabolism Unit, ASL, Pescara, Italy; Department of Medicine and Aging Sciences DMSI and Center for Advanced Studies and Technology CAST, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
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Palanca A, Ampudia-Blasco FJ, Calderón JM, Sauri I, Martinez-Hervás S, Trillo JL, Redón J, Real JT. Comparison of GLP-1 receptor agonists and other Glucose-Lowering agents on cardiovascular outcomes in individuals with type 2 diabetes and Obesity: A Spanish Real-World Population-Based study. Diabetes Res Clin Pract 2024; 207:111071. [PMID: 38142748 DOI: 10.1016/j.diabres.2023.111071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/10/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
AIMS Assess the impact of glucagon-like peptide receptor agonists (GLP-1RA) compared to other glucose-lowering agents on cardiovascular outcomes in individuals with type 2 diabetes and obesity in a Spanish metropolitan area. METHODS A retrospective population-based type 2 diabetes cohort was identified from the Valencia Clinic-Malvarrosa Department electronic databases (2014-2019). Study groups included GLP-1RA, sodium-glucose co-transporter-2 inhibitors (SGLT2i), Insulin, and Miscellany (other glucose-lowering agents). 1:1:1:1 propensity score matching was conducted. The primary outcome was a composite of major adverse cardiovascular events (4-point MACE) comprising myocardial infarction, stroke, all-cause mortality, and heart failure. Secondary outcomes included individual 4-point MACE components. Hazard ratios were estimated using Cox regression analyses against the Miscellany group. RESULTS From 26,944 subjects, 1,848 adults were selected per group. GLP-1RA did not show a significant reduction in 4-point MACE risk (HR 1.05 [95%CI 0.82-1.34]). SGLT2i significantly reduced the risk of heart failure (HR 0.16 [95%CI 0.05-0.54]) and atrial fibrillation (HR 0.58, [95%CI 0.35-0.95]). The Insulin group exhibited a higher risk for 4-point MACE and most individual outcomes compared to GLP-1RA and SGLT2i. CONCLUSIONS Our findings do not provide evidence of a reduced cardiovascular risk, as assessed by 4-point MACE, with GLP-1RA. In contrast, SGLT2i demonstrated protective effects against heart failure and atrial fibrillation.
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Affiliation(s)
- Ana Palanca
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain.
| | - F Javier Ampudia-Blasco
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain; Department of Endocrinology & Nutrition, Clinic University Hospital of Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Spain.
| | | | | | - Sergio Martinez-Hervás
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain; Department of Endocrinology & Nutrition, Clinic University Hospital of Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Spain
| | - José Luis Trillo
- Department of Health of Valencia Clínico-Malvarrosa, Valencia, Spain
| | - Josep Redón
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - José T Real
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain; Department of Endocrinology & Nutrition, Clinic University Hospital of Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Spain
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Morieri ML, Candido R, Frontoni S, Disoteo O, Solini A, Fadini GP. Clinical Features, Cardiovascular Risk Profile, and Therapeutic Trajectories of Patients with Type 2 Diabetes Candidate for Oral Semaglutide Therapy in the Italian Specialist Care. Diabetes Ther 2023; 14:2159-2172. [PMID: 37848758 PMCID: PMC10597935 DOI: 10.1007/s13300-023-01490-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/05/2023] [Indexed: 10/19/2023] Open
Abstract
INTRODUCTION This study aimed to address therapeutic inertia in the management of type 2 diabetes (T2D) by investigating the potential of early treatment with oral semaglutide. METHODS A cross-sectional survey was conducted between October 2021 and April 2022 among specialists treating individuals with T2D. A scientific committee designed a data collection form covering demographics, cardiovascular risk, glucose control metrics, ongoing therapies, and physician judgments on treatment appropriateness. Participants completed anonymous patient questionnaires reflecting routine clinical encounters. The preferred therapeutic regimen for each patient was also identified. RESULTS The analysis was conducted on 4449 patients initiating oral semaglutide. The population had a relatively short disease duration (42% < 5 years), and a minority (15.6%) had a history of cardiovascular events. Importantly, oral semaglutide was started in subjects with various disease durations and background therapies. Notably, its initiation was accompanied by de-prescription of sulfonylureas, pioglitazone, DPP-4 inhibitors, and insulin. Choice of oral semaglutide was influenced by patient profiles and ongoing glucose-lowering regimens. Factors such as younger age, higher HbA1c, and ongoing SGLT-2 inhibitor therapy drove the choice of oral semaglutide with the aim of improving glycemic control. Projected glycemic effectiveness analysis revealed that oral semaglutide could potentially lead HbA1c to target in > 60% of patients, and more often than sitagliptin or empagliflozin. CONCLUSION The study supports the potential of early implementation of oral semaglutide as a strategy to overcome therapeutic inertia and enhance T2D management.
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Affiliation(s)
- Mario Luca Morieri
- Division of Metabolic Diseases, Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Riccardo Candido
- Diabetes Centre, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Simona Frontoni
- Unit of Endocrinology, Diabetes and Metabolism, Department of Systems Medicine, S. Giovanni Calibita Fatebenefratelli Hospital, University of Rome Tor Vergata, Rome, Italy
| | | | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Gian Paolo Fadini
- Division of Metabolic Diseases, Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
- Veneto Institute of Molecular Medicine, Padua, Italy.
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Huang X, Chen H, Wen S, Dong M, Zhou L, Yuan X. Therapeutic Approaches for Nonalcoholic Fatty Liver Disease: Established Targets and Drugs. Diabetes Metab Syndr Obes 2023; 16:1809-1819. [PMID: 37366486 PMCID: PMC10290856 DOI: 10.2147/dmso.s411400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD), as a multisystemic disease, is the most prevalent chronic liver disease characterized by extremely complex pathogenic mechanisms and multifactorial etiology, which often develops as a consequence of obesity, metabolic syndrome. Pathophysiological mechanisms involved in the development of NAFLD include diet, obesity, insulin resistance (IR), genetic and epigenetic determinants, intestinal dysbiosis, oxidative/nitrosative stress, autophagy dysregulation, hepatic inflammation, gut-liver axis, gut microbes, impaired mitochondrial metabolism and regulation of hepatic lipid metabolism. Some of the new drugs for the treatment of NAFLD are introduced here. All of them achieve therapeutic objectives by interfering with certain pathophysiological pathways of NAFLD, including fibroblast growth factors (FGF) analogues, peroxisome proliferator-activated receptors (PPARs) agonists, glucagon-like peptide-1 (GLP-1) agonists, G protein-coupled receptors (GPCRs), sodium-glucose cotransporter-2 inhibitors (SGLT-2i), farnesoid X receptor (FXR), fatty acid synthase inhibitor (FASNi), antioxidants, etc. This review describes some pathophysiological mechanisms of NAFLD and established targets and drugs.
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Affiliation(s)
- Xiaojing Huang
- Graduate School of Fudan University, Shanghai, People’s Republic of China
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, People’s Republic of China
| | - Huiling Chen
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, People’s Republic of China
| | - Song Wen
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, People’s Republic of China
| | - Meiyuan Dong
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, People’s Republic of China
| | - Ligang Zhou
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, People’s Republic of China
| | - Xinlu Yuan
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, People’s Republic of China
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Cesaro A, Acerbo V, Vetrano E, Signore G, Scherillo G, Rotolo FP, De Michele G, Scialla F, Raucci G, Panico D, Gragnano F, Moscarella E, Galiero R, Caturano A, Ruggiero R, Sasso FC, Calabrò P. Sodium-Glucose Cotransporter 2 Inhibitors in Patients with Diabetes and Coronary Artery Disease: Translating the Benefits of the Molecular Mechanisms of Gliflozins into Clinical Practice. Int J Mol Sci 2023; 24:8099. [PMID: 37175805 PMCID: PMC10179032 DOI: 10.3390/ijms24098099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) were initially developed for the treatment of diabetes due to their antihyperglycemic activity. However, in the light of the most recent clinical studies, they are revolutionizing the approach to cardiovascular disease in patients with and without diabetes. We aimed to generate real-world data about the use of SGLT2i in patients with T2DM and coronary artery disease (CAD), focusing on their effectiveness in glycemic control, adherence, long-term efficacy, and safety outcomes. On the basis of the inclusion and exclusion criteria, 143 patients were enrolled. Patients were treated with canagliflozin (n = 33 patients; 23%), dapagliflozin (n = 52 patients, 36.4%), empagliflozin (n = 48 patients; 33.6%), or ertugliflozin (n = 10 patients; 7%) as monotherapy or in combination with other antidiabetic drugs. All patients performed a clinical visit, and their medical history, blood sampling, and anthropometric parameters were measured at discharge and at 1-year follow-up. The reduction in HbA1c % value at 12 months was significant (8.2 vs. 7.4; p < 0.001). Trends in body weight and body mass index also confirmed the positive effect of the treatment (p < 0.0001), as did the reduction in abdominal adiposity (expressed via waist circumference). At 1-year follow-up, 74.1% of patients were adherent to the treatment, and 81.1% were persistent to the treatment. A total of 27 patients (18.8%) had to discontinue treatment early due to drug intolerance caused by genitourinary infections (11.9%), the drub being permanently ineffective (HbA1c not at target or decreasing: 4.9%), or because of expressing. a desire not to continue (2%). No major drug-related adverse events (diabetic ketoacidosis, Fournier's gangrene, lower-limb amputations) occurred at follow-up, while MACE events occurred in 14 patients (9.8%). In real-world patients with T2DM and CAD, SGLT2i have been effective in long-term glycemic control and the improvement in anthropometric indices with good tolerance, high adherence, persistence to treatment, and no major adverse events at 1-year follow-up.
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Affiliation(s)
- Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, I-80131 Naples, Italy
- Division of Clinical Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, I-81100 Caserta, Italy
| | - Vincenzo Acerbo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, I-80131 Naples, Italy
- Division of Clinical Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, I-81100 Caserta, Italy
| | - Erica Vetrano
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia 2, I-80138 Naples, Italy (F.C.S.)
| | - Giovanni Signore
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, I-80131 Naples, Italy
- Division of Clinical Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, I-81100 Caserta, Italy
| | - Gianmaria Scherillo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, I-80131 Naples, Italy
- Division of Clinical Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, I-81100 Caserta, Italy
| | - Francesco Paolo Rotolo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, I-80131 Naples, Italy
- Division of Clinical Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, I-81100 Caserta, Italy
| | - Gianantonio De Michele
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, I-80131 Naples, Italy
- Division of Clinical Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, I-81100 Caserta, Italy
| | - Francesco Scialla
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, I-80131 Naples, Italy
- Division of Clinical Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, I-81100 Caserta, Italy
| | - Giuseppe Raucci
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, I-80131 Naples, Italy
- Division of Clinical Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, I-81100 Caserta, Italy
| | - Domenico Panico
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, I-80131 Naples, Italy
- Division of Clinical Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, I-81100 Caserta, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, I-80131 Naples, Italy
- Division of Clinical Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, I-81100 Caserta, Italy
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, I-80131 Naples, Italy
- Division of Clinical Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, I-81100 Caserta, Italy
| | - Raffaele Galiero
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia 2, I-80138 Naples, Italy (F.C.S.)
| | - Alfredo Caturano
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia 2, I-80138 Naples, Italy (F.C.S.)
| | - Roberto Ruggiero
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia 2, I-80138 Naples, Italy (F.C.S.)
| | - Ferdinando Carlo Sasso
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia 2, I-80138 Naples, Italy (F.C.S.)
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, I-80131 Naples, Italy
- Division of Clinical Cardiology, A.O.R.N. “Sant’Anna e San Sebastiano”, I-81100 Caserta, Italy
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Romera I, Rubio-de Santos M, Artola S, Suárez Fernández C, Conget I. GLP-1 RAs in Spain: A Short Narrative Review of Their Use in Real Clinical Practice. Adv Ther 2023; 40:1418-1429. [PMID: 36821026 PMCID: PMC10070220 DOI: 10.1007/s12325-023-02442-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/24/2023] [Indexed: 02/24/2023]
Abstract
Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) are a class of drugs with potent glucose-lowering activity. Additionally, some GLP-1 RAs have demonstrated cardiovascular and renal benefits. Current guidelines recommend their use in patients with type 2 diabetes (T2D) at high risk of or with established cardiovascular disease (CVD), regardless of glycaemic control, with lifestyle modification and metformin. However, several studies have recently highlighted the limited number of patients with T2D benefiting from these medications worldwide. Given the huge burden of CVD among patients with T2D, efforts should be made to bring clinical practice closer to expert guidelines. This review describes the current situation of GLP-1 RA use in Spain and the reasons behind the gap between guidelines and real-world practice and suggests possible solutions. Administrative issues, lack of awareness of the cardiovascular benefits, clinical inertia, rejection of injectable medication and costs could be some of the reasons for the current situation. Possible strategies that could help to close the gap include encouraging a multidisciplinary approach to the treatment of diabetes which involves cardiologists, endocrinologists, nephrologists, primary care providers and pharmacists; improved awareness of comorbidities and earlier evaluation and treatment or risks; and better education of healthcare providers regarding the cardioprotective benefits of these drugs.
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Affiliation(s)
- Irene Romera
- Eli Lilly and Company, Avda. de la Industria 30, 28108, Alcobendas, Madrid, Spain.
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Luthra R, Bender S, Terada D. Use of Concurrent Anti-diabetes Medications in Patients With Type 2 Diabetes in Clinical Practice in the United States. Clin Ther 2022; 44:1248-1256. [PMID: 36068100 DOI: 10.1016/j.clinthera.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/13/2022] [Accepted: 07/18/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE This report describes the use of combination therapy in patients with type 2 diabetes mellitus (T2DM) who had been initially prescribed metformin in the United States. METHODS Retrospective claims data from a de-identified database were used to identify individuals aged ≥18 years with ≥1 claim for a metformin-containing regimen dated between January 1, 2018, and December 31, 2018. Demographics, insurance type, and prescriber type were compared among subgroups receiving two (dual) or three or more (triple+) anti-diabetes therapies. All analyses were descriptive; no formal comparisons were conducted. FINDINGS Data from 353,062 patients were included. Demographic and other baseline characteristics were similar between the groups receiving dual or triple+ therapy (n = 213,871 and 139,191, respectively). A small age difference was observed between patients receiving dual versus triple+ therapy (mean [SD], 66.5 [11.8] and 65.8 [10.8] years, respectively). Mean (SD) glycosylated hemoglobin levels were lower among patients receiving dual therapy versus triple+ therapy: 7.6% (1.7) versus 8.0% (1.7). The most frequent combination was metformin plus a sulfonylurea (33.4%). The percentage receiving combination therapy with newer treatments was relatively low, and slightly greater in younger patients. Total health care costs were similar with dual and triple+ therapies. IMPLICATIONS The current descriptive analysis demonstrated generally similar features, with regard to the evaluated factors, in cohorts receiving dual versus triple+ T2DM therapy. However, differences between unmeasured factors could exist and require further evaluation. These findings, based on data from a cohort of patients from clinical practice who had initially been prescribed metformin, provide a useful snapshot of current prescribing practices and can be used to inform future research and evidence-based policy decisions.
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Affiliation(s)
- Rakesh Luthra
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| | - Shaun Bender
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut
| | - Derek Terada
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut.
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Hirose N, Tsujimoto N, Katayose T, Chin R. Utilization of glucagon-like peptide-1 receptor agonists and changes in clinical characteristics in patients with type 2 diabetes by chronic kidney disease stage in Japan: A descriptive observational study using a nationwide electronic medical records database. Diabetes Obes Metab 2022; 24:486-498. [PMID: 34779098 PMCID: PMC9300085 DOI: 10.1111/dom.14600] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 01/24/2023]
Abstract
AIM To describe the utilization of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and changes in clinical characteristics before and after GLP-1 RA initiation in patients with type 2 diabetes (T2D) by chronic kidney disease (CKD) stage. MATERIALS AND METHODS In this retrospective descriptive study using a nationwide electronic medical records database in Japan, we included patients with GLP-1 RA prescriptions from June 2010 to October 2019. Clinical characteristics at GLP-1 RA initiation, persistence proportion, and changes in clinical measurements after GLP-1 RA initiation were described for all patients and by CKD stage, defined by baseline estimated glomerular filtration rate (eGFR). RESULTS We included 8049 patients. During the study period, the proportion of patients with T2D initiating GLP-1 RAs increased from 1.5% in 2010 to 3.3% in 2019. Also, the mean (95% confidence interval) of baseline age and eGFR ranged from 58.6 (56.7-60.4) to 66.3 (65.5-67.2) years and from 72.9 (68.0-77.9) to 64.0 (62.2-65.8) mL/min/1.73m2 , respectively. The persistence proportion at 12 months was 49.5% overall, 37.8% in T2D patients with CKD with a baseline eGFR of less than 30 mL/min/1.73m2 , and 34.6% in those undergoing dialysis. The rate of deterioration in renal function reduced after GLP-1 RA initiation. CONCLUSIONS The utilization of GLP-1 RAs has been increasing over the past decade, and GLP-1 RAs have been used in patients with limited treatment options, such as the elderly or those with CKD. In T2D patients with CKD, the persistence proportion of GLP-1 RAs was not low, and the renal dysfunction may be moderated by GLP-1 RA initiation.
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Harris ST, Patorno E, Zhuo M, Kim SC, Paik JM. Prescribing Trends of Antidiabetes Medications in Patients With Type 2 Diabetes and Diabetic Kidney Disease, a Cohort Study. Diabetes Care 2021; 44:dc210529. [PMID: 34344714 PMCID: PMC8929186 DOI: 10.2337/dc21-0529] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 06/21/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess changes in antidiabetes medication class prescriptions over time among patients with diabetic kidney disease (DKD), characteristics of patients prescribed these medications, and prescribers' specialty. RESEARCH DESIGN AND METHODS We conducted a cohort study design using insurance claims data between 2013 and the first quarter of 2020 (2020Q1). Included are adult patients with DKD who initiated a new antidiabetes medication between 2013 and 2020Q1 (N = 160,489 patients). The primary outcome is the yearly and quarterly percent of medication initiation for each antidiabetes medication class over all antidiabetes medication initiations. RESULTS For patients with DKD, sodium-glucose cotransporter 2 inhibitor (SGLT2i) and glucago-like peptide 1 receptor agonist (GLP-1RA) initiations steadily increased between 2013 and 2020Q1. Internists and endocrinologists were the most frequent prescriber specialties. Patients <65 years of age had a larger percentage of all initiations that were SGLT2i or GLP-1RA, 16% and 23%, respectively, in 2019, and patients >75 years of age had a smaller percentage of all initiations that were SGLT2i or GLP-1RA, 11% and 13%, in 2019. CONCLUSIONS For patients with DKD, SGLT2i and GLP-1RA prescriptions have increased over time, likely reflecting evolving prescribing patterns in response to the results of recent clinical trials and new clinical guidelines.
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Affiliation(s)
- Samantha T Harris
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Harvard Business School, Boston, MA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Min Zhuo
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Division of Renal (Kidney) Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Division of Renal (Kidney) Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA
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12
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Bonora BM, Rigato M, Frison V, D'Ambrosio M, Tadiotto F, Lapolla A, Simioni N, Paccagnella A, Avogaro A, Fadini GP. Deintensification of basal-bolus insulin after initiation of GLP-1RA in patients with type 2 diabetes under routine care. Diabetes Res Clin Pract 2021; 173:108686. [PMID: 33548335 DOI: 10.1016/j.diabres.2021.108686] [Citation(s) in RCA: 9] [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: 12/09/2020] [Revised: 01/15/2021] [Accepted: 01/22/2021] [Indexed: 10/22/2022]
Abstract
AIMS We evaluated de-intensification of basal-bolus insulin (BBI) after initiation of a GLP-1 receptor agonist (GLP-1RA) under routine care. RESEARCH DESIGN AND METHODS This retrospective, multicenter study conducted at outpatient clinics in North-East Italy collected data on patients with T2D on BBI who initiated a GLP-1RA. Patients were divided according to whether they de-intensified BBI at the end of observation by stopping prandial insulin. RESULTS We included 425 patients with mean age of 61.3 years and 13 years of diabetes duration. Baseline HbA1c was 8.6% and BMI was 35.5 kg/m2. After 14 months. 58.6% of patients de-intensified BBI after initiating GLP-1RA: they were younger, had a shorter disease duration, lower HbA1c and insulin dose, and less frequent microangiopathy than those who continued BBI. A probability estimation based on these variables was validated in an independent cohort of 40 patients. Body weight improved in both groups, but HbA1c and fasting plasma glucose significantly declined only among patients who de-intensified BBI. Patients who de-intensified BBI and persisted on GLP-1RA at the last observation (80.7%) had greater HbA1c reductions. CONCLUSION Under routine care, GLP-1RA initiation frequently allowed discontinuing BBI, especially among patients with shorter disease duration, lower insulin requirement, and better glucose control.
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Affiliation(s)
| | | | - Vera Frison
- Internal Medicine and Diabetology Service, ULSS6, Cittadella, Italy
| | | | | | - Annunziata Lapolla
- Department of Medicine, University of Padova, 35128 Padova, Italy; Diabetology Service ULSS6, Padova, Italy
| | - Natalino Simioni
- Internal Medicine and Diabetology Service, ULSS6, Cittadella, Italy
| | | | - Angelo Avogaro
- Department of Medicine, University of Padova, 35128 Padova, Italy
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Gallwitz B, Giorgino F. Clinical Perspectives on the Use of Subcutaneous and Oral Formulations of Semaglutide. Front Endocrinol (Lausanne) 2021; 12:645507. [PMID: 34267725 PMCID: PMC8276717 DOI: 10.3389/fendo.2021.645507] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/03/2021] [Indexed: 12/13/2022] Open
Abstract
Early and effective glycemic control can prevent or delay the complications associated with type 2 diabetes (T2D). The benefits of glucagon-like peptide-1 receptor agonists (GLP-1RAs) are becoming increasingly recognized and they now feature prominently in international T2D treatment recommendations and guidelines across the disease continuum. However, despite providing effective glycemic control, weight loss, and a low risk of hypoglycemia, GLP-1RAs are currently underutilized in clinical practice. The long-acting GLP-1RA, semaglutide, is available for once-weekly injection and in a new once-daily oral formulation. Semaglutide is an advantageous choice for the treatment of T2D since it has greater efficacy in reducing glycated hemoglobin and body weight compared with other GLP-1RAs, has demonstrated benefits in reducing major adverse cardiovascular events, and has a favorable profile in special populations (e.g., patients with hepatic impairment or renal impairment). The oral formulation represents a useful option to help improve acceptance and adherence compared with injectable formulations for patients with a preference for oral therapy, and may lead to earlier and broader use of GLP-1RAs in the T2D treatment trajectory. Oral semaglutide should be taken on an empty stomach, which may influence the choice of formulation. As with most GLP-1RAs, initial dose escalation of semaglutide is required for both formulations to mitigate gastrointestinal adverse events. There are also specific dose instructions to follow with oral semaglutide to ensure sufficient gastric absorption. The evidence base surrounding the clinical use of semaglutide is being further expanded with trials investigating effects on diabetic retinopathy, cardiovascular outcomes, and on the common T2D comorbidities of obesity, chronic kidney disease, and non-alcoholic steatohepatitis. These will provide further information about whether the benefits of semaglutide extend to these other indications.
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Affiliation(s)
- Baptist Gallwitz
- Department of Medicine IV - Diabetes, Endocrinology, Nephrology, Tübingen University Hospital, Tübingen, Germany
- *Correspondence: Baptist Gallwitz,
| | - Francesco Giorgino
- Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
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Longato E, Di Camillo B, Sparacino G, Tramontan L, Avogaro A, Fadini GP. Cardiovascular effectiveness of human-based vs. exendin-based glucagon like peptide-1 receptor agonists: a retrospective study in patients with type 2 diabetes. Eur J Prev Cardiol 2020; 28:22-29. [PMID: 33624059 DOI: 10.1093/eurjpc/zwaa081] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 01/20/2023]
Abstract
AIMS Glucagon like peptide-1 (GLP-1) receptor agonists (GLP-1RA) are effective to control type 2 diabetes (T2Ds) and can protect from adverse cardiovascular outcomes. GLP-1RA are based on the human GLP-1 or the exendin-4 sequence. We compared cardiovascular outcomes of patients with T2D who received human-based or exendin-based GLP-1RA in routine clinical practice. METHODS AND RESULTS We performed a retrospective study on the administrative database of T2D patients from the Veneto Region (North-East Italy). We identified patients who initiated a human-based or exendin-based GLP-1RA from 2011 to 2018. The primary outcome was occurrence of major adverse cardiovascular events (MACE). Secondary outcomes were individual MACE components, revascularization, hospitalization for heart failure, or for cardiovascular causes. From 330 193 patients with diabetes, 6620 were new users of GLP-1RA. After propensity score matching, we analysed 1098 patients in each group, who were on average 61 years old, 59.5% males, 13% with established cardiovascular disease, had an estimated diabetes duration of 8.4 years, and a baseline HbA1c of 7.9%. During a median follow-up of 18 months, patients treated with human-based GLP-1RA as compared to those treated with exendin-based GLP-1RA, showed lower rates of MACE [hazard ratio 0.61; 95% confidence interval (CI) 0.39-0.95], myocardial infarction (0.51; 95% CI 0.28-0.94), and hospitalization for cardiovascular causes (0.66; 95% CI 0.47-0.92). CONCLUSION We observed better cardiovascular outcomes among patients treated with human-based vs. exendin-based GLP-1RA under routine care. In the absence of comparative trials and in view of the limitations of retrospective studies, this finding provides a moderate level of evidence to guide clinical decision.
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Affiliation(s)
- Enrico Longato
- Department of Information Engineering, University of Padova, Via Gradenico, 35100 Padova, Italy
| | - Barbara Di Camillo
- Department of Information Engineering, University of Padova, Via Gradenico, 35100 Padova, Italy
| | - Giovanni Sparacino
- Department of Information Engineering, University of Padova, Via Gradenico, 35100 Padova, Italy
| | - Lara Tramontan
- Arsenàl.IT, Veneto's Research Centre for eHealth Innovation, Viale Guglielmo Oberdan, 5, 31100 Treviso, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100 Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100 Padova, Italy
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Teshome G, Ambachew S, Fasil A, Abebe M. Efficacy of Glucagon-Like Peptide-1 Analogs in Nonalcoholic Fatty Liver Disease: A Systematic Review. Hepat Med 2020; 12:139-151. [PMID: 33061687 PMCID: PMC7522518 DOI: 10.2147/hmer.s265631] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/01/2020] [Indexed: 12/13/2022] Open
Abstract
Background Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease. It is believed to be the hepatic manifestation of the metabolic syndrome. Many treatment approaches have been suggested so far, and several types of studies have been done to find treatment for NAFLD, the most promising of which are those with lifestyle interventions. Objective The aim of this systematic review was to evaluate the efficacy and safety of glucagon-like peptide-1 (GLP-1) analogs on the management of NAFLD. Methods The PubMed, MEDLINE, and Cochrane Central Library were searched to identify randomized controlled trials, single arm trials, and cohorts that compared GLP-1 analogs with a control treatment or baseline values with respect to efficacy and safety in patients living with NAFLD. The key outcomes were a change in serum transaminase, resolution of disease status measured by imaging or histological techniques, improvement in insulin resistance, and reduction in body weight. Results Initial searching retrieved 201 peer-reviewed articles and abstracts. Ten studies met all inclusion criteria. The review included a total of 590 participants with NAFLD. Following administration of GLP-1 analogs, a decrease in serum transaminases, improvement in liver histology and insulin resistance, and a reduction in body weight were observed. Compared with baseline, body weight, alanine aminotransferase, aspartate aminotransferase, and gamma glutamyltransferase were decreased by 5.5%, 59.5%, 52.8%, and 44.8%, respectively, due to GLP-1. Likewise, a reduction of proinflammatory cytokines and fibrosis markers and an enhancement of protective adipokines were observed in some of the studies. Conclusion The decrease in a key biochemical marker of liver injury following treatment with GLP-1 analogs, as well as improvements in imaging and histology, suggests that these agents may be effective alternatives for managing NAFLD. Registration CRD42018087262.
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Affiliation(s)
- Getnet Teshome
- University of Gondar Comprehensive Specialized Hospital, University of Gondar, Gondar, Amhara, Ethiopia
| | - Sintayehu Ambachew
- Department of Clinical Chemistry, University of Gondar, Gondar, Amhara, Ethiopia
| | - Alebachew Fasil
- Department of Clinical Chemistry, University of Gondar, Gondar, Amhara, Ethiopia
| | - Molla Abebe
- Department of Clinical Chemistry, University of Gondar, Gondar, Amhara, Ethiopia
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Longato E, Di Camillo B, Sparacino G, Tramontan L, Avogaro A, Fadini GP. Better cardiovascular outcomes of type 2 diabetic patients treated with GLP-1 receptor agonists versus DPP-4 inhibitors in clinical practice. Cardiovasc Diabetol 2020; 19:74. [PMID: 32522260 PMCID: PMC7288543 DOI: 10.1186/s12933-020-01049-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/05/2020] [Indexed: 02/07/2023] Open
Abstract
Background Cardiovascular outcome trials in high-risk patients showed that some GLP-1 receptor agonists (GLP-1RA), but not dipeptidyl-peptidase-4 inhibitors (DPP-4i), can prevent cardiovascular events in type 2 diabetes (T2D). Since no trial has directly compared these two classes of drugs, we performed a comparative outcome analysis using real-world data. Methods From a database of ~ 5 million people from North-East Italy, we retrospectively identified initiators of GLP-1RA or DPP-4i from 2011 to 2018. We obtained two balanced cohorts by 1:1 propensity score matching. The primary outcome was the 3-point major adverse cardiovascular events (3P-MACE; a composite of death, myocardial infarction, or stroke). 3P-MACE components and hospitalization for heart failure were secondary outcomes. Results From 330,193 individuals with T2D, we extracted two matched cohorts of 2807 GLP-1RA and 2807 DPP-4i initiators, followed for a median of 18 months. On average, patients were 63 years old, 60% male; 15% had pre-existing cardiovascular disease. The rate of 3P-MACE was lower in patients treated with GLP-1RA compared to DPP4i (23.5 vs. 34.9 events per 1000 person-years; HR: 0.67; 95% C.I. 0.53–0.86; p = 0.002). Rates of myocardial infarction (HR 0.67; 95% C.I. 0.50–0.91; p = 0.011) and all-cause death (HR 0.58; 95% C.I. 0.35–0.96; p = 0.034) were lower among GLP-1RA initiators. The as-treated and intention-to-treat approaches yielded similar results. Conclusions Patients initiating a GLP-1RA in clinical practice had better cardiovascular outcomes than similar patients who initiated a DPP-4i. These data strongly confirm findings from cardiovascular outcome trials in a lower risk population.
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Affiliation(s)
- Enrico Longato
- Department of Information Engineering, University of Padova, 35100, Padua, Italy
| | - Barbara Di Camillo
- Department of Information Engineering, University of Padova, 35100, Padua, Italy
| | - Giovanni Sparacino
- Department of Information Engineering, University of Padova, 35100, Padua, Italy
| | - Lara Tramontan
- Arsenàl.IT, Veneto's Research Centre for eHealth Innovation, 31100, Treviso, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100, Padua, Italy.
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Morieri ML, Rigato M, Frison V, Simioni N, D'Ambrosio M, Tadiotto F, Paccagnella A, Lapolla A, Avogaro A, Fadini GP. Effectiveness of dulaglutide vs liraglutide and exenatide once-weekly. A real-world study and meta-analysis of observational studies. Metabolism 2020; 106:154190. [PMID: 32109448 DOI: 10.1016/j.metabol.2020.154190] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/14/2020] [Accepted: 02/24/2020] [Indexed: 01/14/2023]
Abstract
INTRODUCTION AND AIM Real-word data on the head-to-head comparisons among glucagon-like peptide-1 receptor agonists (GLP-1RA) are scant. Therefore, we aimed to compare the effectiveness of dulaglutide versus liraglutide and exenatide once weekly (exeOW) in type 2 diabetic (T2D) patients under routine care. METHODS This was a retrospective, multicenter, real-world study on patients with T2D (aged 18-80) initiating a GLP-1RA between 2010 and 2018 at specialist outpatient clinics. We compared the effectiveness of dulaglutide versus liraglutide and exeOW on the changes in HbA1c (primary outcome), body weight, blood pressure and fasting glucose (secondary outcomes). Average follow-up was 5.9 months. Channelling biases were addressed with propensity score matching or multivariable adjustment. Meta-analyses of observational studies, covering the same comparisons, are also presented. RESULTS 849, 1371 and 198 patients were included in the dulaglutide, liraglutide and exeOW groups, respectively. The reduction of HbA1c was greater with dulaglutide than with liraglutide (-0.24 ± 0.08%; p = 0.003), and was confirmed in the meta-analysis of observational studies. In our study, dulaglutide showed similar effectiveness compared to exeOW. When these results were pooled with other observational studies, dulaglutide showed a greater reduction of HbA1c (-0.19%; p = 0.003) and body weight (-0.8 kg; p = 0.007). CONCLUSIONS In a real-world scenario, dulaglutide reduced HbA1c more than liraglutide. Conversely, we found similar effect of dulaglutide and exeOW, with statistical differences arising solely when results were meta-analysed with those from other observational studies. Lack of up-titration for liraglutide and higher discontinuation rate for exeOW likely influenced the estimated treatment difference.
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Affiliation(s)
- Mario Luca Morieri
- Department of Medicine, University of Padova, 35128 Padova, Italy; Division of Metabolic Diseases, Padova Hospital, 35128 Padova, Italy
| | | | - Vera Frison
- Internal Medicine and Diabetology Service, ULSS6, 35013 Cittadella, Italy
| | - Natalino Simioni
- Internal Medicine and Diabetology Service, ULSS6, 35013 Cittadella, Italy
| | | | | | | | - Annunziata Lapolla
- Department of Medicine, University of Padova, 35128 Padova, Italy; Diabetology Service ULSS6, 35100 Padova, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, 35128 Padova, Italy; Division of Metabolic Diseases, Padova Hospital, 35128 Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, 35128 Padova, Italy; Division of Metabolic Diseases, Padova Hospital, 35128 Padova, Italy.
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Sciannameo V, Berchialla P, Orsi E, Lamacchia O, Morano S, Querci F, Consoli A, Avogaro A, Fadini GP. Enrolment criteria for diabetes cardiovascular outcome trials do not inform on generalizability to clinical practice: The case of glucagon-like peptide-1 receptor agonists. Diabetes Obes Metab 2020; 22:817-827. [PMID: 31943710 DOI: 10.1111/dom.13962] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/26/2019] [Accepted: 01/08/2020] [Indexed: 02/06/2023]
Abstract
AIM To evaluate the generalizability of cardiovascular outcome trials (CVOTs) on glucagon-like peptide-1 receptor agonists (GLP-1RAs), we assessed what proportion of real-world patients with type 2 diabetes (T2D) constitute true CVOT-like populations. MATERIALS AND METHODS We applied inclusion/exclusion (I/E) criteria of each GLP-1RA CVOT to a cross-sectional database of 281 380 T2D patients from Italian diabetes outpatient clinics. We calculated the proportion of patients eligible for each CVOT and compared their clinical characteristics with those of trial patients. In addition, we used a Bayesian network-based method to sample the greatest subsets of real-world patients yielding true CVOT-like populations. RESULTS Between 98 725 and 124 164 T2D patients could be evaluated for CVOT eligibility. After excluding patients who were already on GLP-1RAs and applying I/E criteria, 35.8% of patients would be eligible for REWIND, 34.1% for PIONEER-6, 13.4% for EXSCEL, 10.1% for SUSTAIN-6, 9.5% for HARMONY and 9.4% for LEADER. Overall, 45.4% of patients could be eligible for at least one of the CVOTs. These patients, however, were extremely different to trial patients in most of the clinical characteristics, including demographics, concomitant medications and complications. The greatest CVOT-like subsets of real-world patients were 0.5% for SUSTAIN-6, 1.0% for EXSCEL, 1.2% for LEADER, 1.8% for PIONEER-6 and 7.9% for REWIND. CONCLUSIONS A very small proportion of real-world patients constitute true CVOT-like populations. These findings question whether any meaningful information can be drawn from applying trial enrolment criteria to real-world T2D patients.
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Affiliation(s)
- Veronica Sciannameo
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Emanuela Orsi
- Unit of Endocrinology and Metabolic Diseases, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Olga Lamacchia
- Unit of Endocrinology, Department of Medical and Surgical Sciences, University Hospital of Foggia, Foggia, Italy
| | - Susanna Morano
- Unit of Diabetes Complications, V Clinica Medica, Department of Experimental Medicine, University of Rome "La Sapienza", Rome, Italy
| | - Fabrizio Querci
- Unit of Diabetology, ASST Bergamo Est, Alzano Lombardo, Italy
| | - Agostino Consoli
- Department of Medicine and Aging Science, "G. D'Annunzio" University of Chieti, Chieti, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova, Italy
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Morieri ML, Avogaro A, Fadini GP. Long-Acting Injectable GLP-1 Receptor Agonists for the Treatment of Adults with Type 2 Diabetes: Perspectives from Clinical Practice. Diabetes Metab Syndr Obes 2020; 13:4221-4234. [PMID: 33204129 PMCID: PMC7665457 DOI: 10.2147/dmso.s216054] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022] Open
Abstract
Randomized controlled trials (RCTs) have consistently shown glycemic and extra-glycemic benefits of long-acting injectable glucagon-like-peptide-1 receptor agonists (GLP-1RAs, liraglutide, albiglutide, exenatide once-weekly, dulaglutide, and semaglutide) in terms of reduction in the rates of cardiovascular events and mortality among patients with type 2 diabetes. Recently, the analyses of large datasets collecting routinely-accumulated data from clinical practice (ie, real-world studies, RWS) have provided new opportunities to complement the information obtained from RCTs. In this narrative review, we addressed clinically relevant questions that might be answered by well-conducted RWS: are subjects treated with GLP-1RAs in the "real-world" similar to those included in RCTs? Is the performance of GLP-1RA observed in the RWS (effectiveness) similar to that described in RCTs (efficacy)? Is the effectiveness similar in population of patients generally under-represented in RCTs? Are the cardiovascular benefits of GLP-1RAs confirmed in RWS? We also describe a few comparisons currently un-explored by specific RCTs, such as direct comparison between different administration strategies (eg, fixed- versus flexible-combination with basal-insulin) or between GLP-1RAs versus dipeptidyl-peptidase-4 inhibitor (DDP4i) or versus sodium/glucose cotransporter-2 inhibitors (SGLT-2i) on hard cardio-renal outcomes. Altogether, RWS provide highly informative information on treatment with GLP-1RAs. On the one side, RWS showed different clinical characteristics between subjects enrolled in RCTs versus those attending real-world clinics and receiving a GLP-1RA. On the other hand, RWS showed that GLP-1RA effectiveness is overall consistent in subgroups of patients less represented in RCTs. In addition, RWS allowed the identification of modifiable factors (eg, titration or adherence) that might guide physicians towards better GLP-1RAs use. Finally, multiple RWS reported better cardio-renal outcomes with GLP-1RAs than with DPP-4i, while initial findings from RWS described a weaker cardiovascular protection compared to SGLT-2i. Therefore, there is the need for further RWS and RCTs comparing these different classes of glucose lowering medications.
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Affiliation(s)
- Mario Luca Morieri
- Department of Medicine, University of Padova, Padova35128, Italy
- Correspondence: Mario Luca Morieri Department of Medicine, University of Padova, Via Giustiniani 2, Padova35128, ItalyTel +39 049 8217094 Email
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova35128, Italy
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