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Vaidya S, Atal S, Joshi R. Willingness to Pay (WTP) for Newer Treatment Options for Diabetes: A Study Among Patients at a Tertiary Care Centre. Cureus 2024; 16:e56103. [PMID: 38618372 PMCID: PMC11009894 DOI: 10.7759/cureus.56103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction Type 2 diabetes mellitus (T2DM) poses a substantial burden globally and particularly in India, affecting health, finances, and overall quality of life. The management of this condition relies on lifestyle modifications and advanced pharmacological interventions, with emerging drugs showing promise in areas such as administration, side effects, efficacy, and cardiovascular benefits. However, their market penetration is hindered by high costs. Understanding the target population's expectations and willingness to pay (WTP) for these drugs is crucial. WTP, a key concept in behavioral science, reflects the maximum price consumers are willing to pay for a product, aiding in healthcare cost-effectiveness evaluations. Despite its relevance, only one WTP study has been conducted in the Indian context for diabetes. This study explores WTP for two novel drugs: oral semaglutide and icodec (weekly insulin). Material and methods This observational study, conducted in a diabetes specialty clinic and telemedicine facility in All India Institute of Medical Sciences, Bhopal, India, involved adults (18-80 years) diagnosed with T2DM. Data collection adhered to ethical guidelines, and participants provided written informed consent. Face-to-face interviews were employed to gather socio-economic, demographic, and medical details. Participants estimated their WTP for oral semaglutide and weekly insulin, considering reference ranges for existing antidiabetic treatments. Statistical analyses, including t-tests and analysis of variance, explored sociodemographic and clinical factors influencing WTP. Results Of 105 approached patients, 87 (74.3%) participated. The majority were males (55.2%) with an average age of 57.2 years. The average WTP for oral semaglutide was INR 9.35±5.66 per pill, significantly lower than its market price (INR 315). For weekly insulin (icodec), the WTP was INR 157.25±112.60 per dose. Subgroup analyses revealed no significant correlations based on sociodemographic or clinical parameters. Conclusion This study demonstrated the feasibility of WTP assessments in an Indian outpatient setting, revealing a substantial cost disparity between patients' WTP for oral semaglutide and its market price. The findings underscore the importance of considering WTP in introducing new diabetes medications in India, offering valuable insights for healthcare decision-makers and developers.
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Affiliation(s)
- Shrutangi Vaidya
- Endocrinology and Diabetes, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Shubham Atal
- Pharmacology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Rajnish Joshi
- Internal Medicine, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
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Yang YS, Kim NH, Baek JH, Ko SH, Son JW, Lee SH, Rhee SY, Kim SK, Sohn TS, Jun JE, Jeong IK, Kim CH, Song K, Rhee EJ, Noh J, Hur KY. Real-World Treatment Patterns according to Clinical Practice Guidelines in Patients with Type 2 Diabetes Mellitus and Established Cardiovascular Disease in Korea: Multicenter, Retrospective, Observational Study. Diabetes Metab J 2024; 48:279-289. [PMID: 38273793 PMCID: PMC10995487 DOI: 10.4093/dmj.2023.0225] [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: 07/13/2023] [Accepted: 08/12/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGRUOUND Recent diabetes management guidelines recommend that sodium-glucose cotransporter 2 inhibitors (SGLT2is) or glucagon-like peptide 1 receptor agonists (GLP-1RAs) with proven cardiovascular benefits should be prioritized for combination therapy in patients with type 2 diabetes mellitus (T2DM) and established cardiovascular disease (CVD). This study was aimed at evaluating SGLT2i or GLP-1RA usage rates and various related factors in patients with T2DM and established CVD. METHODS We enrolled adults with T2DM aged ≥30 years who were hospitalized due to established CVD from January 2019 to May 2020 at 13 secondary and tertiary hospitals in Korea in this retrospective observational study. RESULTS Overall, 2,050 patients were eligible for analysis among 2,107 enrolled patients. The mean patient age, diabetes duration, and glycosylated hemoglobin level were 70.0 years, 12.0 years, and 7.5%, respectively. During the mean follow-up duration of 9.7 months, 25.7% of the patients were prescribed SGLT2is after CVD events. However, only 1.8% were prescribed GLP-1RAs. Compared with SGLT2i non-users, SGLT2i users were more frequently male and obese. Furthermore, they had a shorter diabetes duration but showed worse glycemic control and better renal function at the time of the event. GLP-1RA users had a longer duration of diabetes and worse glycemic control at the time of the event than GLP-1RA non-users. CONCLUSION The SGLT2i or GLP-1RA prescription rates were suboptimal in patients with T2DM and established CVD. Sex, body mass index, diabetes duration, glycemic control, and renal function were associated with the use of these agents.
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Affiliation(s)
- Ye Seul Yang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Nam Hoon Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jong Ha Baek
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - Seung-Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jang Won Son
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Seung-Hwan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Youl Rhee
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Soo-Kyung Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Tae Seo Sohn
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Ji Eun Jun
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Korea
| | - In-Kyung Jeong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Chong Hwa Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea
| | - Keeho Song
- Division of Endocrinology and Metabolism, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Eun-Jung Rhee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Junghyun Noh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Committee of Clinical Practice Guidelines, Korean Diabetes Association
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Sejong General Hospital, Bucheon, Korea
- Division of Endocrinology and Metabolism, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Nakamura K, Kamei K, Austin J, Marwaha S, Piercy J, Anderson P, Sakaki-Yumoto M, Ohyama M. Degree of Alignment Between Japanese Patients and Physicians on Alopecia Areata Disease Severity and Treatment Satisfaction: A Real-World Survey. Dermatol Ther (Heidelb) 2024; 14:151-167. [PMID: 38079099 PMCID: PMC10828166 DOI: 10.1007/s13555-023-01067-y] [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: 09/15/2023] [Accepted: 11/02/2023] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Alopecia areata (AA) is characterized by non-scarring scalp and/or body hair loss and can negatively impact patient mental health. Data are limited on the alignment of patient and physician perceptions of AA severity with each other and with Japanese Dermatological Association (JDA) guideline criteria, and of patient-physician alignment on treatment satisfaction. Therefore, we performed analyses to compare JDA severity groupings with patient-physician alignment on disease severity and to explore treatment satisfaction in AA in Japan. METHODS Data were drawn from the Adelphi AA Disease Specific Programme (DSP)™, a real-world survey of physicians and patients with AA in Japan conducted January-March 2021. Patients and physicians reported patient AA severity as mild, moderate or severe based on their subjective judgement. Patients were then categorized into five hair loss severity groups according to JDA criteria (S1-5), and patient-physician pairs were matched to assess alignment on severity and treatment satisfaction. RESULTS Subjective patient- and physician-reported disease severity generally followed JDA severity groupings. The percentage of patient-physician alignment on severity recognition was 76.3% in the overall population. In misaligned pairs, 20.2%, 14.5%, 7.3%, 25.0% and 0.0% of physicians rated disease as more severe than patients in S1, S2, S3, S4 and S5, respectively. Regarding treatment satisfaction, patient-physician alignment was 57.6% in the overall population. In S5, 46.2% of physicians reported being less satisfied than patients. Both physicians and patients cited lack of efficacy as the main reason for dissatisfaction. Of 221 patients, 39.8% and 29.9% were categorized as borderline-abnormal cases for anxiety and depression, respectively. CONCLUSIONS This study highlights previously unreported patient-physician misalignment on disease severity, level of treatment dissatisfaction and unmet needs due to the lack of effective treatment. Further study on how improvement of the misalignment between physicians and patients could increase both patient and physician satisfaction with treatment and improve the quality of life for patients with AA.
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Affiliation(s)
| | | | | | | | | | | | | | - Manabu Ohyama
- Department of Dermatology, Kyorin University Faculty of Medicine, Tokyo, Japan.
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Shang J, Yan W, Cui X, Ma W, Wang Z, Liu N, Yi X, Guo T, Wei X, Sun Y, Hu H, Cui W, Chen L. Schisandrin B, a potential GLP-1R agonist, exerts anti-diabetic effects by stimulating insulin secretion. Mol Cell Endocrinol 2023; 577:112029. [PMID: 37495090 DOI: 10.1016/j.mce.2023.112029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/21/2023] [Accepted: 07/23/2023] [Indexed: 07/28/2023]
Abstract
Diabetes mellitus is a metabolic disease that is characterized by elevated blood sugar. Although glucagon-like peptide-1 receptor agonists (GLP-1RA) lower blood glucose in a glucose-dependent manner, most of them are macromolecule polypeptides. Macromolecular peptides are relatively expensive and inconvenient compared with small molecules. Therefore, this study sought to identify the small molecules binding to GLP-1R via cell membrane chromatography (CMC), confirm their agonistic activity, and further study its beneficial effects in a mouse model of type 2 diabetes mellitus (T2DM) induced by a combination of high-fat diet and streptozotocin. We used CMC, calcium imaging and molecular docking techniques to screen and identify the potential small molecule Schisandrin B (Sch B), which exhibits a strong binding effect to GLP-1R, from the small molecule library of traditional Chinese medicine. Through in-vitro experiments, we found that Sch B stimulated insulin secretion in β-TC-6 cells, while GLP-1R antagonist Exendin9-39, adenylate cyclase inhibitor SQ22536, and protein kinase A (PKA) inhibitor H89 could significantly inhibit the insulin secretion induced by Sch B. In vivo, Sch B significantly improved fasting blood glucose levels, intraperitoneal glucose tolerance test damage, and the status of pancreatic tissue damage, and reduced serum insulin levels, total cholesterol, triglyceride and low density lipoprotein in T2DM mice. These results indicate that Sch B alleviates T2DM by promoting insulin release through the GLP-1R/cAMP/PKA signaling pathway, suggesting that Sch B may be a potential GLP-1RA, which is expected to provide a new therapeutic strategy for the prevention and treatment of T2DM.
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Affiliation(s)
- Jia Shang
- Department of Pharmacology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China; Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University, Xi'an, 710061, China
| | - Wenhui Yan
- Department of Pharmacology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China; Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University, Xi'an, 710061, China; Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, Xi'an, 710061, China
| | - Xin Cui
- Department of Pharmacology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China; Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University, Xi'an, 710061, China
| | - Weina Ma
- School of Pharmacy, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China
| | - Zhuanzhuan Wang
- Department of Pharmacology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China; Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University, Xi'an, 710061, China
| | - Na Liu
- Department of Pharmacology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China; Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University, Xi'an, 710061, China
| | - Xinyao Yi
- Department of Pharmacology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China; Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University, Xi'an, 710061, China
| | - Tingli Guo
- Department of Pharmacology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China; Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University, Xi'an, 710061, China
| | - Xiaotong Wei
- Department of Pharmacology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China; Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University, Xi'an, 710061, China
| | - Yuzhuo Sun
- Department of Pharmacology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China; Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University, Xi'an, 710061, China
| | - Hao Hu
- Department of Pharmacology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China; Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University, Xi'an, 710061, China; Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, Xi'an, 710061, China
| | - Wei Cui
- Department of Endocrinology and Second Department of Geriatrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China; International Obesity and Metabolic Disease Research Center (IOMC), Xi'an Jiaotong University, Xi'an, 710061, China.
| | - Lina Chen
- Department of Endocrinology and Second Department of Geriatrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China; Department of Pharmacology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, China; Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University, Xi'an, 710061, China; Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education, Xi'an, 710061, China; International Obesity and Metabolic Disease Research Center (IOMC), Xi'an Jiaotong University, Xi'an, 710061, China; Cardiometabolic Innovation Center, Ministry of Education, Xi'an, 710061, China.
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Hu S, Wu D, Wu J, Zhang Y, Bøgelund M, Pöhlmann J, Pollock RF. Disutilities Associated with Intravenous Iron Infusions: Results from a Time Trade-off Survey and Diminishing Marginal Utility Model for Treatment Attributes in China. Patient Relat Outcome Meas 2023; 14:253-267. [PMID: 37789883 PMCID: PMC10543423 DOI: 10.2147/prom.s400389] [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] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 09/15/2023] [Indexed: 10/05/2023] Open
Abstract
Purpose Treatment process attributes can affect health state utilities associated with therapy. For intravenous iron, used to treat iron deficiency and iron deficiency anemia, research into process attributes is still lacking. This study estimated utilities associated with process attributes for intravenous iron infusions. Methods An online survey including seven health state vignettes and time trade-off tasks was administered to participants, who were not patients living with iron deficiency or iron deficiency anemia, from a Chinese online panel. Vignettes used an identical description of iron deficiency and iron deficiency anemia but differed in the annual number of infusions, infusion duration, and infusion-associated risk of hypophosphatemic osteomalacia. Disutilities and their rate of change as the number of infusions increased were examined using a power model. Results The survey was completed by 1091 participants. The highest utilities were observed for one annual infusion of 15-30 minutes or 30-60 minutes, without risk of hypophosphatemic osteomalacia (0.754 and 0.746, respectively). In comparison, more infusions and infusions with a risk of hypophosphatemic osteomalacia were associated with lower utilities. Utility continued to decrease, but at a diminishing rate, as the annual number of infusions increased, with utility decrements of 0.006 and 0.002, respectively, when going from zero to one and from four to five infusions per year. All marginal disutilities were small (values <0.01). Conclusion This study suggested that treatment attributes of intravenous iron infusions affect health state utilities. Using intravenous iron formulations that allow for fewer and shorter infusions without the risk of hypophosphatemic osteomalacia can reduce the number of visits required and increase patients' quality of life.
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Affiliation(s)
- Shanlian Hu
- School of Public Health, Fudan University, Shanghai, People’s Republic of China
| | - Depei Wu
- First Affiliated Hospital of Soochow University, Soochow University, Suzhou, People’s Republic of China
| | - Jing Wu
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, People’s Republic of China
| | - Yabing Zhang
- Shanghai Institute of Technology, Shanghai, People’s Republic of China
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Kweon S, Lee JH, Yang SB, Park SJ, Subedi L, Shim JH, Cho SS, Choi JU, Byun Y, Park J, Park JW. Design of chimeric GLP-1A using oligomeric bile acids to utilize transporter-mediated endocytosis for oral delivery. Biomater Res 2023; 27:83. [PMID: 37660070 PMCID: PMC10474648 DOI: 10.1186/s40824-023-00421-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/19/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Despite the effectiveness of glucagon-like peptide-1 agonist (GLP-1A) in the treatment of diabetes, its large molecular weight and high hydrophilicity result in poor cellular permeability, thus limiting its oral bioavailability. To address this, we developed a chimeric GLP-1A that targets transporter-mediated endocytosis to enhance cellular permeability to GLP-1A by utilizing the transporters available in the intestine, particularly the apical sodium-dependent bile acid transporter (ASBT). METHODS In silico molecular docking and molecular dynamics simulations were used to investigate the binding interactions of mono-, bis-, and tetra-deoxycholic acid (DOCA) (monoDOCA, bisDOCA, and tetraDOCA) with ASBT. After synthesizing the chimeric GLP-1A-conjugated oligomeric DOCAs (mD-G1A, bD-G1A, and tD-G1A) using a maleimide reaction, in vitro cellular permeability and insulinotropic effects were assessed. Furthermore, in vivo oral absorption in rats and hypoglycemic effect on diabetic db/db mice model were evaluated. RESULTS In silico results showed that tetraDOCA had the lowest interaction energy, indicating high binding affinity to ASBT. Insulinotropic effects of GLP-1A-conjugated oligomeric DOCAs were not different from those of GLP-1A-Cys or exenatide. Moreover, bD-G1A and tD-G1A exhibited improved in vitro Caco-2 cellular permeability and showed higher in vivo bioavailability (7.58% and 8.63%) after oral administration. Regarding hypoglycemic effects on db/db mice, tD-G1A (50 μg/kg) lowered the glucose level more than bD-G1A (50 μg/kg) compared with the control (35.5% vs. 26.4%). CONCLUSION GLP-1A was conjugated with oligomeric DOCAs, and the resulting chimeric compound showed the potential not only for glucagon-like peptide-1 receptor agonist activity but also for oral delivery. These findings suggest that oligomeric DOCAs can be used as effective carriers for oral delivery of GLP-1A, offering a promising solution for enhancing its oral bioavailability and improving diabetes treatment.
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Affiliation(s)
- Seho Kweon
- Department of Molecular Medicine and Biopharmaceutical Science, Graduate School of Convergence Science and Technology, Seoul National University, Seoul, 08826, Republic of Korea
- Biomedicine Cutting Edge Formulation Technology Center, Mokpo National University, Jeonnam, 58554, Republic of Korea
| | - Jun-Hyuck Lee
- Department of Applied Life Science, Graduate School, BK21 Program, Konkuk University, Chungju, 27478, Republic of Korea
| | - Seong-Bin Yang
- Department of Applied Life Science, Graduate School, BK21 Program, Konkuk University, Chungju, 27478, Republic of Korea
| | - Seong Jin Park
- College of Pharmacy, Seoul National University, Seoul, 08826, Republic of Korea
| | - Laxman Subedi
- Biomedicine Cutting Edge Formulation Technology Center, Mokpo National University, Jeonnam, 58554, Republic of Korea
- Department of Biomedicine, Health & Life Convergence Sciences, BK21 Four, Biomedical and Healthcare Research Institute, Mokpo National University, Jeonnam, 58554, Republic of Korea
| | - Jung-Hyun Shim
- Biomedicine Cutting Edge Formulation Technology Center, Mokpo National University, Jeonnam, 58554, Republic of Korea
- Department of Biomedicine, Health & Life Convergence Sciences, BK21 Four, Biomedical and Healthcare Research Institute, Mokpo National University, Jeonnam, 58554, Republic of Korea
- College of Pharmacy and Natural Medicine Research Institute, Mokpo National University, Jeonnam, 58554, Republic of Korea
| | - Seung-Sik Cho
- Department of Biomedicine, Health & Life Convergence Sciences, BK21 Four, Biomedical and Healthcare Research Institute, Mokpo National University, Jeonnam, 58554, Republic of Korea
- College of Pharmacy and Natural Medicine Research Institute, Mokpo National University, Jeonnam, 58554, Republic of Korea
| | - Jeong Uk Choi
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Chonnam National University, Gwangju, 61186, Republic of Korea
| | - Youngro Byun
- College of Pharmacy, Seoul National University, Seoul, 08826, Republic of Korea
| | - Jooho Park
- Department of Applied Life Science, Graduate School, BK21 Program, Konkuk University, Chungju, 27478, Republic of Korea.
| | - Jin Woo Park
- Biomedicine Cutting Edge Formulation Technology Center, Mokpo National University, Jeonnam, 58554, Republic of Korea.
- Department of Biomedicine, Health & Life Convergence Sciences, BK21 Four, Biomedical and Healthcare Research Institute, Mokpo National University, Jeonnam, 58554, Republic of Korea.
- College of Pharmacy and Natural Medicine Research Institute, Mokpo National University, Jeonnam, 58554, Republic of Korea.
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Khamnueva LY, Andreeva LS. [Efficacy of treatment with glucagon-like peptide receptor agonists-1 in Asian patients with type 2 diabetes mellitus]. PROBLEMY ENDOKRINOLOGII 2023; 69:38-46. [PMID: 37448270 DOI: 10.14341/probl13245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/17/2023] [Accepted: 02/19/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND The projected 68% increase in patients with type 2 diabetes mellitus (T2D) in the upcoming decades and the specific pathophysiological course of the disease are critical factors for the development of optimal disease management tactics in the Asian population. It is now known that β-cell dysfunction is dominant in the pathogenesis of T2D in Asians. In a number of Asian countries, incretin therapy is the leading therapy. AIM To review literature on glucagon-like peptide-1 (GLP-1) secretion and clinical trial results of GLP-1 receptor agonist class (GLP-1RA) drugs as well as to evaluate their effectiveness in Asian population with T2D. MATERIALS AND METHODS A review of studies on pathophysiological aspects of GLP-1 secretion and evaluation of the efficacy of therapy with GLP-1RA preparations registered and used in clinical practice in Asian regions. RESULTS Several studies in Asian countries have shown that intact GLP-1 levels were significantly lower in both T2D patients and healthy Japanese volunteers; as well as in patients with impaired glucose tolerance. It is suggested that either impaired secretion of GLP-1 in the gut, accelerated processing by dipeptidyl peptidase-4, or a combination of both are responsible for the decrease in GLP-1. The greater efficacy of GLP-1RA treatment in achieving glycemic control in Asian T2D patients was presented by Kim Y.G. et al. in a meta-analysis of 15 randomised controlled trials, the reduction in HbA1c on GLP-1RA treatment averaged -1.16% in Asian-dominated studies and -0.83% in non-Asian-dominated studies. In the PIONEER 9 clinical programme, similar results were obtained, with oral semaglutide having a more pronounced effect on glycaemic control in Japanese patients. Thus, the mean change in HbA 1c was -1.1%, 7 mg -1.5%, and 14 mg -1.7% at the 3 mg dose; whereas in the PIONEER 1 study in the global population, the mean change in HbA1c was -0.6%, -0.9% and -1.1% for 3, 7, 14 mg semaglutide, respectively. The PIONEER 10 study concluded that oral semaglutide was well tolerated by Japanese patients with T2D. Oral semaglutide reduced HbA1c (14 mg dose) and body weight (7 and 14 mg doses) more significantly compared to dulaglutide at 0.75 mg dose. Results of a pooled analysis of long-acting GLP-1RA showed a more significant reduction in cardiovascular event risk in the Asian subpopulation. CONCLUSION The presented review describes benefits in glycemic control as well as in the reduction of relative cardiovascular event risks with GLP-1RA treatment in the Asian population, which requires further in-depth research and implies optimal management tactics in patients with T2DM.
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Ono R, Furihata K, Ichikawa Y, Nakazuru Y, Bergman A, Gorman DN, Saxena AR. A phase 1 study to evaluate the safety, tolerability, pharmacokinetics and pharmacodynamics of danuglipron (PF-06882961), an oral small-molecule glucagon-like peptide-1 receptor agonist, in Japanese adults with type 2 diabetes mellitus. Diabetes Obes Metab 2023; 25:805-814. [PMID: 36433713 PMCID: PMC10107991 DOI: 10.1111/dom.14928] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/14/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
AIMS This study investigated the safety, tolerability, pharmacokinetics and pharmacodynamics of danuglipron (PF-06882961), which is a novel, oral small-molecule glucagon-like peptide-1 receptor agonist, in Japanese participants with type 2 diabetes mellitus (T2DM). MATERIALS AND METHODS This phase 1, randomized, double-blind, placebo-controlled, parallel-group study enrolled adult Japanese participants with T2DM inadequately controlled on diet and exercise. Participants received twice-daily oral doses of placebo or multiple ascending doses of danuglipron titrated to 40, 80 or 120 mg twice daily over 8 weeks. The primary outcome was the safety and tolerability of danuglipron. Secondary and exploratory outcomes included plasma pharmacokinetics, glycaemic parameters and body weight. RESULTS In the 37 participants randomized, the most common treatment-emergent adverse events were nausea, vomiting, abdominal discomfort, diarrhoea and headache. Most treatment-emergent adverse events were of mild or moderate intensity. Dose-proportional increases in danuglipron exposure parameters were observed at steady state (Day 56). Significant reductions from baseline were observed with danuglipron on Day 56 for mean daily glucose [least squares mean (90% confidence interval) placebo-adjusted difference of up to -67.89 (-88.98, -46.79) mg/dl] and on Day 57 for fasting plasma glucose [up to -40.87 (-53.77, -27.98) mg/dl], glycated haemoglobin [up to -1.41% (-2.01%, -0.82%)] and body weight [up to -1.87 (-3.58, -0.17) kg]. CONCLUSIONS In Japanese adults with T2DM, danuglipron exhibited dose-proportional increases in plasma exposure at steady state and robustly reduced glycaemic parameters and body weight after 8 weeks of dosing, with a safety profile consistent with the mechanism of action.
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Affiliation(s)
- Ryosuke Ono
- Pfizer Research and Development Japan, Tokyo, Japan
| | | | | | | | - Arthur Bergman
- Pfizer Worldwide Research and Development, Cambridge, Massachusetts, USA
| | - Donal N Gorman
- Pfizer Worldwide Research and Development, Cambridge, UK
| | - Aditi R Saxena
- Pfizer Worldwide Research and Development, Cambridge, Massachusetts, USA
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9
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Panchal R, Nguyen D, Ghule P, Li N, Giannouchos T, Pan RJ, Biskupiak J, Britton L, Nohavec R, Slager S, Ngorsuraches S, Brixner D. Understanding patient cost-sharing thresholds for diabetes treatment attributes via a discrete choice experiment. J Manag Care Spec Pharm 2023; 29:139-150. [PMID: 36705280 PMCID: PMC10387929 DOI: 10.18553/jmcp.2023.29.2.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND: The process used to prefer certain products across drug classes for diabetes is generally focused on comparative effectiveness and cost. However, payers rarely tie patient preference for treatment attributes to formulary management resulting in a misalignment of value defined by providers, payers, and patients. OBJECTIVES: To explore patients' willingness to pay (WTP) for the predetermined high-value and low-value type 2 diabetes mellitus (T2DM) treatments within a health plan. METHODS: A cross-sectional discrete choice experiment (DCE) survey was used to determine patient preference for the benefit, risk, and cost attributes of T2DM treatments. A comprehensive literature review of patient preference studies in diabetes and a review of guidelines and medical literature identified study attributes. Patients and diabetes experts were interviewed and instructed to identify, prioritize, and comment on which attributes of diabetes treatments were most important to T2DM patients. The patients enrolled in a health plan were asked to respond to the survey. A multinomial logit model was developed to determine the relative importance and the patient's WTP of each attribute. The patients' relative values based on WTPs for T2DM treatments were calculated and compared with the treatments by a health plan. RESULTS: A total of 7 attributes were selected to develop a web-based DCE questionnaire survey. The responses from a total of 58 patients were analyzed. Almost half (48.3%) of the respondents took oral medications and injections for T2DM. The most prevalent side effects due to diabetes medications were gastrointestinal (43.1%), followed by weight gain (39.7%) and nausea (32.8%). Patients were willing to pay more for treatments with proven cardiovascular benefit and for the risk reduction of hospitalization from heart failure. On the other hand, they would pay less for treatments with higher gastrointestinal side effects. Patients were willing to pay the most for sodium-glucose cotransporter 2 inhibitor and glucagon-like peptide 1 receptor agonist agents and the least for dipeptidyl peptidase-4 inhibitors and thiazolidinediones. CONCLUSIONS: This study provides information to better align patient, provider, and payer preferences in both benefit design and value-based formulary strategy for diabetes treatments. A preferred placement of treatments with cardiovascular benefits and lower adverse gastrointestinal side effects may lead to increased adherence to medications and improved clinical outcomes at a lower overall cost to both patients and their health plan. DISCLOSURES: This study was supported by a grant from the PhRMA Foundation.
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Affiliation(s)
- Rupesh Panchal
- Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City.,University of Utah Health Plans, Murray
| | - Danielle Nguyen
- Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City
| | - Priyanka Ghule
- Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City
| | - Niying Li
- Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City
| | | | - Raymond J Pan
- Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City
| | - Joseph Biskupiak
- Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City
| | - Laura Britton
- Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City.,University of Utah Health Plans, Murray
| | - Robert Nohavec
- Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City.,University of Utah Health Plans, Murray
| | - Stacey Slager
- Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City
| | | | - Diana Brixner
- Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City
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10
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Gelhorn HL, Osumili B, Brown K, Ross MM, Schulz A, Fernandez G, Boye KS. The Impact of Substantial Improvements in HbA1c and Weight Loss on the Medication Preferences of People with Type 2 Diabetes. Patient Prefer Adherence 2023; 17:793-805. [PMID: 36987498 PMCID: PMC10040168 DOI: 10.2147/ppa.s401465] [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: 12/14/2022] [Accepted: 03/10/2023] [Indexed: 03/30/2023] Open
Abstract
PURPOSE To quantify the preferences of people with type 2 diabetes (T2D) for treatment attributes of a glucose-dependent insulinotropic polypeptide (GIP)/glucagon-like peptide-1 (GLP-1) receptor agonist (RA) versus an injectable GLP-1 RA medication profile. PATIENTS AND METHODS Injection-naive people taking oral medications for T2D in the US and UK completed a web survey including a discrete choice experiment to quantify patients' preferences for five treatment attributes: delivery system, frequency of nausea, frequency of hypoglycemia, HbA1c reduction, and weight reduction. Attributes and levels were based on head-to-head clinical trial data of tirzepatide 5mg, 10mg, and 15mg versus semaglutide 1mg. Preference data were analyzed separately by country using multinomial mixed logit (MXL) models. MXL parameters were used to estimate the predicted preference for each tirzepatide dose versus semaglutide 1mg. Direct preferences for each dose of tirzepatide versus semaglutide 1mg were elicited. RESULTS Participants (N=620) in the US (N=301) and UK (N=319) were 50.8% and 50.5% female with mean ages of 60.7 years and 58.9 years, respectively. The order and magnitude of relative attribute importance (RAI) scores differed between countries. HbA1c reduction (26.3%) had the greatest impact on US participants' preferences, and hypoglycemia (32.8%) did among UK participants. Attribute-level marginal utility results indicated preferences for greater HbA1c improvements, the single-use pre-filled pen, lower hypoglycemia, greater weight reductions, and lower frequency of nausea. Assuming the availability of only tirzepatide or semaglutide 1mg, the predicted preference for tirzepatide (5, 10, and 15mg) in the US is 95.6% (vs 4.4% for semaglutide 1mg) and in the UK was 86.3% (vs 13.7% for semaglutide 1mg). CONCLUSION HbA1c reduction, frequency of hypoglycemia, and weight reduction are key drivers of preferences among people with T2D when considering medication options. Overall, people with T2D are likely to prefer the tirzepatide over the semaglutide 1mg medication profiles.
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Affiliation(s)
- Heather L Gelhorn
- Patient-Centered Research, Evidera, Inc., Bethesda, MD, USA
- Correspondence: Heather L Gelhorn, Patient-Centered Research, Evidera, Inc., 7101 Wisconsin Avenue, Suite 1400, Bethesda, MD, 20814, USA, Tel +1-970-363-7333, Email
| | - Beatrice Osumili
- Value, Evidence, and Outcomes, Eli Lilly and Company, Indianapolis, IN, USA
| | - Katelyn Brown
- Value, Evidence, and Outcomes, Eli Lilly and Company, Indianapolis, IN, USA
| | - Melissa M Ross
- Patient-Centered Research, Evidera, Inc., Bethesda, MD, USA
| | - Andrea Schulz
- Patient-Centered Research, Evidera, Inc., Bethesda, MD, USA
| | | | - Kristina S Boye
- Value, Evidence, and Outcomes, Eli Lilly and Company, Indianapolis, IN, USA
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11
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Geng J, Bao H, Feng Z, Meng J, Yu X, Yu H. Investigating patients' preferences for new anti-diabetic drugs to inform public health insurance coverage decisions: a discrete choice experiment in China. BMC Public Health 2022; 22:1860. [PMID: 36199056 PMCID: PMC9533494 DOI: 10.1186/s12889-022-14244-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/21/2022] [Indexed: 11/15/2022] Open
Abstract
Background Diabetes is a major public health concern with a considerable impact on healthcare expenditures. Deciding on health insurance coverage for new drugs that meet patient needs is a challenge facing policymakers. Our study aimed to assess patients’ preferences for public health insurance coverage of new anti-diabetic drugs in China. Methods We identified six attributes of new anti-diabetic drugs and used the Bayesian-efficient design to generate choice sets for a discrete choice experiment (DCE). The DCE was conducted in consecutive samples of type 2 diabetes patients in Jiangsu Province. The mixed logit regression model was applied to estimate patient-reported preferences for each attribute. The interaction model was used to investigate preference heterogeneity. Results Data from 639 patients were available for analysis. On average, the most valued attribute was the improvement in health-related quality of life (HRQoL) (β = 1.383, p < 0.001), followed by positive effects on extending life years (β = 0.787, p < 0.001), and well-controlled glycated haemoglobin (β = 0.724, p < 0.001). The out-of-pocket cost was a negative predictor of their preferences (β = -0.138, p < 0.001). Elderly patients showed stronger preferences for drugs with a lower incidence of serious side effects (p < 0.01) and less out-of-pocket costs (p < 0.01). Patients with diabetes complications favored more in the length of extended life (p < 0.01), improvement in HRQoL (p < 0.05), and less out-of-pocket costs (p < 0.001). Conclusion The new anti-diabetic drugs with significant clinical effectiveness and long-term health benefits should become the priority for public health insurance. The findings also highlight the value of accounting for preference heterogeneity in insurance policy-making. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14244-z.
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Affiliation(s)
- Jinsong Geng
- Medical School of Nantong University, 226001, Nantong, Jiangsu, China.
| | - Haini Bao
- Medical School of Nantong University, 226001, Nantong, Jiangsu, China.,The First People's Hospital of Lianyungang, 222061, Lianyungang, Jiangsu, China
| | - Zhe Feng
- Medical School of Nantong University, 226001, Nantong, Jiangsu, China
| | - Jingyi Meng
- Medical School of Nantong University, 226001, Nantong, Jiangsu, China
| | - Xiaolan Yu
- Medical School of Nantong University, 226001, Nantong, Jiangsu, China
| | - Hao Yu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 02215, Boston, MA, USA
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12
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Sims TJ, Boye KS, Robinson S, Kennedy-Martin T. Treatment-Related Attributes of Diabetes Therapies and How People with Type 2 Diabetes Report Their Impact on Indicators of Medication-Taking Behaviors. Patient Prefer Adherence 2022; 16:1919-1939. [PMID: 35958887 PMCID: PMC9359496 DOI: 10.2147/ppa.s367046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 07/08/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Understanding the treatment-related attributes influencing medication-taking behaviors in people with type 2 diabetes (T2D) is important for delivery of patient-centered care. This review aimed to identify and summarize studies in which people with T2D (PwD) directly indicated the treatment-related attributes associated with medication-taking behaviors or intentions. Materials and Methods EMBASE and PubMed were searched for studies (Jan 2005-May 2021) reporting the link between PwD-expressed diabetes treatment-related attributes and the decision to initiate, adhere to, or discontinue a T2D medication. Eligible studies reported attributes associated with oral antidiabetes drugs or injectables (not insulin). Studies not explicitly exploring the link between attributes and indicators of behaviors (eg most discrete-choice experiments [DCE] and those interrogating electronic medical records or claims databases) were excluded, as were studies where the link between attribute and behavior came from anyone but the PwD. Results Of the 6464 studies identified, 16 were included. Studies were conducted across multiple countries; the USA was most represented (n = 8 studies). The impact of treatment attributes was described on indicators of initiation (n = 3), adherence (n = 12), and discontinuation (n = 4). Some studies evaluated multiple behaviors. PwD perspectives were solicited by structured questionnaires (n = 10), qualitative approaches (n = 4), or DCE explicitly exploring the link to medication-taking behaviors (n = 2). Closed- (n = 9) and open-ended questions (n = 7) were employed. Across studies, several factors including glycemic efficacy (n = 9), weight change (n = 9), dosing frequency (n = 9), hypoglycemia (n = 8), gastrointestinal adverse events (n = 8), regimen complexity (n = 6), route of administration (n = 3), and cardiovascular risk (n = 1) were reported as influencing behaviors, being motivators or barriers to initiation, adherence, or discontinuation. Conclusion Several attributes influence how PwD take their medications. Insights gained directly from PwD have the potential to assist stakeholders in making more informed, patient-centered, treatment decisions, thus choosing and managing medications that PwD are comfortable initiating and persisting with over the longer term.
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13
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Joshi SR, Rajput R, Chowdhury S, Singh AK, Bantwal G, Das AK, Unnikrishnan AG, Saboo BD, Kesavadev J, Ghosal S, Mohan V. The role of oral semaglutide in managing type 2 diabetes in Indian clinical settings: Addressing the unmet needs. Diabetes Metab Syndr 2022; 16:102508. [PMID: 35653929 DOI: 10.1016/j.dsx.2022.102508] [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: 12/20/2021] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 11/26/2022]
Abstract
AIMS Despite their established benefits, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) remain underutilized for type 2 diabetes mellitus (T2DM) management, which indicates that subcutaneous injection is an unfavorable mode of delivery from the patient's perspective. This review summarizes existing challenges related to medication adherence and the use of antihyperglycemia injectables, revisits the established safety and efficacy of oral semaglutide, and explores its features and considerations for use among the Indian T2DM population. METHODS We performed a literature search using MEDLINE and the National Institutes of Health Clinical Trials Registry from July 1, 2016, to July 1, 2021, to identify publications on oral semaglutide approval, T2DM treatment guidelines, and clinical evidence for oral drug formulation. RESULTS Oral semaglutide is the first oral GLP-1 RA approved for T2DM patients based on phase 3, randomized PIONEER trials. The multitargeted action of this drug offers glycemic control, weight control, and cardiovascular, renal, and additional benefits, including patient convenience and enhanced medication adherence. In addition to achieving glycemic control, the cost of semaglutide is reported to be lower than other GLP-1 RA in the West, thus potentially mitigating the economic burden that appears to be high among the Indian population. CONCLUSIONS Currently, there is no data available on oral semaglutide in Indian clinical settings. However, significant improvements in glycemic control, cardiac and renal benefits, as well as weight loss across clinical trials should encourage clinicians to prioritize oral semaglutide over other antidiabetic agents.
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Affiliation(s)
- Shashank R Joshi
- Grant Medical College and Consulting Endocrinologist, Lilavati Hospital, Mumbai, India.
| | - Rajesh Rajput
- Department of Endocrinology, PGIMS, Rohtak, Haryana, India.
| | | | - Awadhesh K Singh
- G. D. Hospital & Diabetes Institute, Kolkata, West Bengal, India.
| | | | - Ashok K Das
- Department of General Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India.
| | | | | | | | | | - Viswanathan Mohan
- Dr. Mohan's Diabetes Specialties Centre & Madras Diabetes Research Foundation, Chennai, India.
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14
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Meier JJ, Granhall C, Hoevelmann U, Navarria A, Plum-Moerschel L, Ramesh C, Tannapfel A, Kapitza C. Effect of upper gastrointestinal disease on the pharmacokinetics of oral semaglutide in subjects with type 2 diabetes. Diabetes Obes Metab 2022; 24:684-692. [PMID: 34957654 DOI: 10.1111/dom.14632] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/06/2021] [Accepted: 12/22/2021] [Indexed: 12/29/2022]
Abstract
AIM To investigate whether upper gastrointestinal (GI) disease has any effect on the exposure of oral semaglutide, an important consideration given that its absorption occurs primarily in the stomach. MATERIALS AND METHODS In an open-label, parallel-group trial (NCT02877355), subjects aged 18-80 years with type 2 diabetes with mild-to-moderate upper GI disease (N = 36; chronic gastritis [n = 5], gastroesophageal reflux disease [n = 8], and both [n = 23]) or without upper GI disease (N = 19) received oral semaglutide 3 mg once daily for 5 days, followed by 7 mg for 5 days. The primary and key supportive endpoints were the area under the semaglutide plasma concentration-time curve (AUC) from 0 to 24 hours after last trial product administration on day 10 (AUC0-24h,day10 ) and the maximum semaglutide plasma concentration (Cmax,day10 ), respectively. RESULTS Semaglutide exposure was not statistically significantly different between subjects with and without upper GI disease. Estimated group ratios (subjects with/without upper GI disease) were 1.18 (95% confidence interval [CI], 0.80, 1.75) for AUC0-24h,day10 and 1.16 (95% CI, 0.77, 1.76) for Cmax . Time to Cmax and semaglutide half-life were similar in subjects with and without upper GI disease. Oral semaglutide was well tolerated; all adverse events were mild-to-moderate, with no withdrawals because of adverse events. CONCLUSIONS There was no significant difference in exposure to oral semaglutide in subjects with or without upper GI disease, hence no dose adjustment is required.
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Affiliation(s)
- Juris J Meier
- Diabetes Division, Department of Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | | | | | | | | | - Chethana Ramesh
- Novo Nordisk Service Centre India Private Ltd, Novo Nordisk, Bangalore, India
| | - Andrea Tannapfel
- Diabetes Division, Department of Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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15
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Singh AK, Singh R, Misra A. Oral semaglutide in type 2 diabetes mellitus: Comprehensive review, critical appraisal and clinical consideration of its use in India. Diabetes Metab Syndr 2022; 16:102436. [PMID: 35245858 DOI: 10.1016/j.dsx.2022.102436] [Citation(s) in RCA: 1] [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: 02/12/2022] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Oral semaglutide is the first glucagon-like petide-1 receptor agonist (GLP-1RA) approved for oral use in the treatment of type 2 diabetes mellitus (T2DM). We aim to conduct a comprehensive review of literature to find out the efficacy and safety of oral semaglutide in T2DM, to lay out a clinical consideration for its use in India. METHODS We searched the electronic database of PubMed and Google Scholar from inception until January 31, 2022, using several MeSH keywords and retrieved all available granular details of phase 1, 2 and 3 randomized controlled trials (RCTs) of oral semaglutide. Subsequently, we reviewed the results critically to lay down the clinical recommendation of its use. RESULTS Ten phase 3 randomized, placebo- and or active-controlled studies of oral semaglutide (PIONEER programs) are currently published. Seven global trials of oral semaglutide (PIONEER 1-5, 7 and 8) that exclusively studied the efficacy (lowering of HbA1c and body weight, achieving target of HbA1c <7% and other composites of HbA1c and weight) outcomes, found 14 mg oral semaglutide to be superior to placebo or active comparators (empagliflozin, sitagliptin and liraglutide). Efficacy was similar in Asians, although no separate data exists for Indians due to the low number of participants. Expectedly, gastrointestinal intolerance were the most commonly observed side effects with oral semaglutide and the main reason for drug discontinuation. CONCLUSION Oral semaglutide 14 mg is an effective agent in the treatment of T2DM. Real-world studies of semaglutide are clearly needed in India in absence of meaningful data from RCTs in Indians.
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Affiliation(s)
| | - Ritu Singh
- G. D Hospital & Diabetes Institute, Kolkata, West Bengal, India
| | - Anoop Misra
- Fortis C-DOC Hospital for Diabetes & Allied Sciences, New Delhi, India; National Diabetes, Obesity and Cholesterol Foundation, New Delhi, India; Diabetes Foundation (India), New Delhi, India
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16
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Liu S, Liu J, Yu Y, Si L, Tang C, Liu Z, Chen Y. What Is Valued Most by Patients With Type 2 Diabetes Mellitus When Selecting Second-Line Antihyperglycemic Medications in China. Front Pharmacol 2022; 12:802897. [PMID: 35002736 PMCID: PMC8733399 DOI: 10.3389/fphar.2021.802897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/22/2021] [Indexed: 11/14/2022] Open
Abstract
Objective: To estimate patient preferences for second-line antihyperglycemic medications in China. Methods: A face to face survey with the best-worst scaling (BWS) choices was administered in patients with diagnosed type 2 diabetes mellitus (T2DM). Study participants were asked to indicate which attribute they valued most and which attribute they valued least in 11 choice sets, each of which consisted of five alternatives out of 11 antihyperglycemic medication-specific attributes (treatment efficacy, weight change, hypoglycemic events, gastrointestinal side effects, cardiovascular health, urinary tract infection and genital infection side effects, edema, mode of administration, bone fracture, dosing frequency and out-of-pocket cost). A counting approach, a conditional logit model, and K-means clustering were used to estimate the relative importance of items and preference heterogeneity. Results: A total of 362 participants were included with a mean age of 63.6 (standard deviation: 11.8) years. There were 56.4% of participants were women, and 56.3% being diagnosed with diabetes for at least 5 years. Efficacy, cardiovascular health and hypoglycemic events were valued most, while dosing frequency, mode of administration and bone fracture were valued least. The K-means clustering further showed preference heterogeneity in out-of-pocket cost across the participants. Conclusion: Our study suggests that treatment efficacy, cardiovascular health and hypoglycemic events are valued most by Chinese patients with T2DM when selecting second-line antihyperglycemic medications. The study improves the understanding of patients’ preferences for second-line antihyperglycemic medications in China.
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Affiliation(s)
- Shimeng Liu
- School of Public Health, Fudan University, Shanghai, China.,NHC Key Laboratory of Health Technology Assessment (Fudan University), Shanghai, China
| | - Jing Liu
- School of Management, Hainan Medical University, Haikou, China
| | - Yijiang Yu
- Huai'an Hospital of Traditional Chinese Medicine, Huai'an, China
| | - Lei Si
- The George Institute for Global Health, UNSW Sydney, Kensington, NSW, Australia
| | - Chengxiang Tang
- School of Public Administration, Guangzhou University, Guangzhou, China
| | - Zhigang Liu
- School of Management, Hainan Medical University, Haikou, China
| | - Yingyao Chen
- School of Public Health, Fudan University, Shanghai, China.,NHC Key Laboratory of Health Technology Assessment (Fudan University), Shanghai, China
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17
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Donnan J, Huang R, Twells L. Patient Preferences for Attributes of Health Canada Approved Weight Loss Medications Among Adults Living with Obesity in Canada: A Qualitative Study. Patient Prefer Adherence 2022; 16:911-923. [PMID: 35411134 PMCID: PMC8994660 DOI: 10.2147/ppa.s350411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/11/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Obesity is a complex disease with negative impacts on physical and mental health. The treatment of obesity is an area where shared decision making and patient preferences play an important role. Recommendations surrounding weight loss medications are evolving and only recently, with the publication of the 2020 Canadian Obesity Management Clinical Guidelines, pharmacotherapy has become a recommended alternative for obesity management. Guidelines recommend three medications: orlistat, liraglutide, and naltrexone/bupropion. This study sought to identify medication attributes relevant to patients starting pharmacotherapy for weight management. PATIENTS AND METHODS Semi-structured focus groups and interviews were conducted with Canadian residents who were ≥18 years of age and were living with obesity (body mass index [BMI] ≥30kg/m2 or ≥27kg/m2 with adiposity-related complications). Sessions were conducted virtually, audio recorded, and transcribed. Two team members used a combination of inductive and deductive coding to independently code the data. A final coding template was agreed upon through discussion. RESULTS A total of 21 individuals participated (85.7% female, 76.2% ≥40 years of age) with the average BMI being 44.3 kg/m2. Participants touched upon many attributes which were categorized into five categories: 1) cost, 2) regimen, 3) side effects, 4) benefits, and 5) non-medication attributes. Cost of medications, lack of coverage by insurance companies, and stigma were identified as major barriers to accessing medications. There was consensus in the desire for a simple regimen, however there was heterogeneity among opinions on tolerability of side effects, desired benefits, and route of administration. CONCLUSION This study identified attributes that influenced patient's decisions when considering a new anti-obesity medication. Understanding these attributes can assist clinicians in shared decision-making. This study highlighted the stigma that is prevalent among providers and the need for education. Further research should be conducted to understand the tradeoffs patients in our study make between the identified attributes.
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Affiliation(s)
- Jennifer Donnan
- School of Pharmacy, Memorial University, St. John’s, Newfoundland and Labrador, Canada
- Correspondence: Jennifer Donnan, Tel +1 709 864-3587, Email
| | - Rita Huang
- School of Pharmacy, Memorial University, St. John’s, Newfoundland and Labrador, Canada
| | - Laurie Twells
- Faculty of Medicine, Memorial University, St. John’s, Newfoundland and Labrador, Canada
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Lv Y, Ren R, Tang C, Song K, Li S, Wang H. Preferences for Patients with Type 2 Diabetes Mellitus for Medications in Shandong Province, China: A Discrete Choice Experiment. Patient Prefer Adherence 2022; 16:2335-2344. [PMID: 36046499 PMCID: PMC9423121 DOI: 10.2147/ppa.s367985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/10/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To evaluate preferences for medications among patients with type 2 diabetes mellitus (T2DM) from urban community health stations or rural village clinics in Shandong province, China. METHODS We use a discrete choice experiment (DCE) to measure the medication preferences. Each patient completed six DCE choice sets. The attributes for the DCE questionnaire include mode of administration, out-of-pocket medication cost per month, fasting blood glucose control effect and frequency of hypoglycemia events. The conditional logit model (Clogit) and mixed logit model (MXL) were used to evaluate choice data. RESULTS A total of 887 patients with T2DM completed the survey. The mean age of participants was 64 years, 36.42% experienced complications, and the mean duration of diabetes was about 8 years. Overall, patients' ideal medication would not have hypoglycemia events, provide normal fasting glucose levels, have oral medication three times a day and lower monthly medication cost. Patients prioritized the frequency of hypoglycemia events (β=15.055, P < 0.01) and were willing to spend CNY 393.10 per month to avoid hypoglycemia events. For patients with higher educational levels and with longer diagnosis time, the effect of fasting blood glucose was more relevant than all other outcomes. CONCLUSION This study provides information on T2DM patients' preference for medications. Our results suggest that clinical doctors should present patients with a variety of pharmaceutical characteristics and include their preference into medication decision, which will improve patient adherence and health outcomes.
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Affiliation(s)
- Yuyu Lv
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, People’s Republic of China
- NHC Key Laboratory of Health Economics and Policy Research (Shandong University), Jinan, People’s Republic of China
| | - Ru Ren
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, People’s Republic of China
- NHC Key Laboratory of Health Economics and Policy Research (Shandong University), Jinan, People’s Republic of China
- Center for Health Preference Research, Shandong University, Jinan, People’s Republic of China
| | - Chengxiang Tang
- Macquarie University Centre for the Health Economy, Macquarie University Business School & Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Kuimeng Song
- School of Health Care Security, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, People’s Republic of China
| | - Shunping Li
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, People’s Republic of China
- NHC Key Laboratory of Health Economics and Policy Research (Shandong University), Jinan, People’s Republic of China
- Center for Health Preference Research, Shandong University, Jinan, People’s Republic of China
- Correspondence: Shunping Li; Haipeng Wang, Centre for Health Management and Policy Research, Wenhua Xi Road 44, Jinan, Shandong Province, 250012, People’s Republic of China, Tel +86-131-8893-4998, +86-186-6899-6362, Email ;
| | - Haipeng Wang
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, People’s Republic of China
- NHC Key Laboratory of Health Economics and Policy Research (Shandong University), Jinan, People’s Republic of China
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Bhattacharyya S, Chawla M, Sanyal D. Glycemic treatment effect of oral semaglutide plus other antidiabetic medications: An Indian experience. JOURNAL OF DIABETOLOGY 2022. [DOI: 10.4103/jod.jod_71_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Meier JJ. Efficacy of Semaglutide in a Subcutaneous and an Oral Formulation. Front Endocrinol (Lausanne) 2021; 12:645617. [PMID: 34248838 PMCID: PMC8269445 DOI: 10.3389/fendo.2021.645617] [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: 03/08/2021] [Indexed: 12/11/2022] Open
Abstract
Despite the benefits of early and effective glycemic control in the management of type 2 diabetes (T2D), achieving glycated hemoglobin (HbA1c) targets is challenging in some patients. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) provide effective reductions in HbA1c and body weight. Semaglutide is the only GLP-1RA that is available in both an injectable and oral formulation. The efficacy of once-weekly subcutaneous semaglutide and once-daily oral semaglutide has been investigated in the global SUSTAIN and PIONEER phase III clinical trial programs in a range of clinical settings, including early T2D managed with diet and exercise only, more established T2D uncontrolled on one to three oral antidiabetic drugs, and advanced disease treated with insulin. Across the SUSTAIN program, once-weekly subcutaneous semaglutide 1.0 mg reduced HbA1c by 1.5-1.8% after 30-56 weeks, which was significantly more than sitagliptin, liraglutide, exenatide extended release, dulaglutide, canagliflozin, or insulin glargine. Across the PIONEER program, once-daily oral semaglutide 14 mg reduced HbA1c by 1.0-1.4%, significantly more than sitagliptin or empagliflozin, and to a similar extent as liraglutide after 26 weeks. In addition, subcutaneous semaglutide reduced body weight significantly more than all active comparators tested, while oral semaglutide reduced body weight more than sitagliptin and liraglutide, and to a similar extent as empagliflozin. Neither formulation of semaglutide has been associated with an increased risk of hypoglycemia and both improve various measures of health-related quality of life. Semaglutide offers the benefits of a highly effective GLP-1RA in both injectable and oral formulations. Selection of the most appropriate formulation can be made on an individual basis to best suit the patient's preferences and needs.
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Affiliation(s)
- Juris J. Meier
- Diabetes Center Bochum-Hattingen, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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Andersen A, Knop FK, Vilsbøll T. A Pharmacological and Clinical Overview of Oral Semaglutide for the Treatment of Type 2 Diabetes. Drugs 2021; 81:1003-1030. [PMID: 33964002 PMCID: PMC8217049 DOI: 10.1007/s40265-021-01499-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2021] [Indexed: 12/04/2022]
Abstract
Oral semaglutide (Rybelsus®) is a glucagon-like peptide-1 (GLP-1) receptor agonist (GLP-1RA) with 94% homology to human GLP-1. It is the first GLP-1RA developed for oral administration, and it comprises a co-formulation of the peptide semaglutide with the absorption enhancer sodium N-(8-[2-hydroxybenzoyl] amino) caprylate, which overcomes the challenges of peptide absorption in the acidic conditions of the stomach. Oral semaglutide is indicated for use as an add-on combination therapy (with other glucose-lowering agents, including insulin) or as a monotherapy (in patients who are intolerant to metformin) for type 2 diabetes when diet and exercise do not provide adequate glycemic control. In an extensive phase III clinical program including patients from across the disease spectrum, treatment with oral semaglutide resulted in effective glycemic control, reductions in body weight, and decreases in systolic blood pressure when used as monotherapy or in combination with other glucose-lowering therapies. Studies showed that oral semaglutide was well tolerated, with a safety profile consistent with the GLP-1RA drug class. The risk of hypoglycemia was low, and the most common adverse events were gastrointestinal, with nausea and diarrhea generally being the most frequently reported manifestations. Cardiovascular (CV) safety was shown to be noninferior to placebo and observations suggest that the CV profile of oral semaglutide is likely to be similar to that of subcutaneous semaglutide. The evolution of the GLP-1RA class to include an oral agent could facilitate the use of these agents earlier in the diabetes treatment cascade owing to wider acceptance from patients and healthcare professionals.
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Affiliation(s)
- Andreas Andersen
- Steno Diabetes Center Copenhagen, Gentofte Hospital, University of Copenhagen, 2900, Gentofte, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Filip Krag Knop
- Steno Diabetes Center Copenhagen, Gentofte Hospital, University of Copenhagen, 2900, Gentofte, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tina Vilsbøll
- Steno Diabetes Center Copenhagen, Gentofte Hospital, University of Copenhagen, 2900, Gentofte, Denmark.
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Ishii H, Hansen BB, Langer J, Horio H. Effect of Orally Administered Semaglutide Versus Dulaglutide on Diabetes-Related Quality of Life in Japanese Patients with Type 2 Diabetes: The PIONEER 10 Randomized, Active-Controlled Trial. Diabetes Ther 2021; 12:613-623. [PMID: 33460016 PMCID: PMC7846658 DOI: 10.1007/s13300-020-00985-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/11/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION In the randomized Peptide InnOvatioN for Early diabEtes tReatment (PIONEER) 10 trial, once-daily orally administered semaglutide-the first oral glucagon-like peptide 1 receptor agonist (GLP-1RA)-was similarly tolerated with comparable (at 7 mg) or better (at 14 mg) efficacy versus the injectable GLP-1RA dulaglutide 0.75 mg. Health-related quality of life (HRQoL) in PIONEER 10 was assessed using the Japanese-specific Diabetes Therapy-Related Quality of Life (DTR-QoL) questionnaire. METHODS The DTR-QoL comprises 29 questions, providing four domain and total scores. Answers were converted to a score between 0 and 100, with higher scores indicating greater HRQoL. Two estimands were prespecified: treatment policy (regardless of treatment discontinuation or rescue medication use) and trial product (assuming on treatment without rescue medication) in all randomized patients. Outcomes were assessed at weeks 26 and 52. RESULTS Mean baseline DTR-QoL domain scores were similar between treatment arms and were generally lower (giving more scope for improvement) for "anxiety and dissatisfaction with treatment" (62.1-65.3) and "satisfaction with treatment" (53.9-57.9) than "burden on social activities and daily activities" (76.5-77.7) and "hypoglycemia" (83.5-88.2). Using the treatment policy estimand, orally administered semaglutide 7 and 14 mg improved HRQoL versus dulaglutide 0.75 mg for the total score (estimated mean change from baseline [CfB] 7.3 and 8.1 vs 3.3; estimated treatment difference [ETD] 3.9 and 4.8) and the "anxiety and dissatisfaction with treatment" domain (CfB 9.7 and 10.9 vs 3.7; ETD 6.0 and 7.2) at week 52. Orally administered semaglutide 14 mg improved the "satisfaction with treatment" domain versus dulaglutide 0.75 mg (CFB 13.8 vs 5.7; ETD 8.1). DTR-QoL scores for orally administered semaglutide tended to be more durable (sustained over time) than for dulaglutide. Outcomes for the trial product estimand were similar. CONCLUSION Orally administered semaglutide 7 and 14 mg improved the patients' HRQoL measured by the Japanese-specific DTR-QoL instrument versus dulaglutide 0.75 mg at week 52. TRIAL REGISTRATION ClinicalTrials.gov NCT03015220.
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Affiliation(s)
- Hitoshi Ishii
- Department of Doctor-Patient Relationships, Nara Medical University, Nara, Japan.
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