Follow the LEADER-Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results Trial

Effects of Liraglutide Compared With Placebo on Events of Acute Gallbladder or Biliary Disease in Patients With Type 2 Diabetes at High Risk for Cardiovascular Events in the LEADER Randomized Trial

OBJECTIVE

To explore gallbladder- and biliary tract-related events reported for the liraglutide and placebo groups in the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) trial.

RESEARCH DESIGN AND METHODS

LEADER was an international, randomized, double-blind, controlled cardiovascular (CV) outcomes trial. Participants with type 2 diabetes at high risk for CV events (n = 9,340) were randomized 1:1 to receive either liraglutide (≤1.8 mg daily; n = 4,668) or placebo (n = 4,672), with both groups also receiving standard care (treatment period: 3.5-5 years). Acute gallstone disease was a medical event of special interest. This post hoc analysis categorized captured events of acute gallbladder or biliary disease into four groups: uncomplicated gallbladder stones, complicated gallbladder stones, cholecystitis, and biliary obstruction. Time to first event by treatment group was analyzed using Cox regression.

RESULTS

There was an increased risk of acute gallbladder or biliary disease with liraglutide versus placebo (n = 141 of 4,668 vs. n = 88 of 4,672 patients, respectively; hazard ratio [HR] 1.60; 95% CI 1.23, 2.09; P < 0.001). Similar trends were observed for each of the four categories of gallbladder- or biliary tract-related events. Cholecystectomy was performed more frequently in liraglutide-treated patients (HR 1.56; 95% CI 1.10, 2.20; P = 0.013) but for similar proportions of the patients who experienced gallbladder- or biliary tract-related events (57% with liraglutide vs. 59% with placebo).

CONCLUSIONS

Although LEADER was not specifically designed to assess acute gallbladder or biliary disease, the trial showed an increased risk of gallbladder- or biliary tract-related events with liraglutide versus placebo, which appeared to be consistent across four categories of these events. Further studies should investigate the relevant mechanisms.

SGLT-2 Inhibitors and GLP-1 Agonists: First-Line Therapy for Diabetes With Established Cardiovascular Disease

There is a growing body of evidence that diabetes represents a significant and largely modifiable risk factor for cardiovascular disease (CVD). It is known to markedly increase the risk of CVD-with CVD accounting for 2 of every 3 deaths in patients with diabetes. It is suggested that once patients with diabetes develop clinical coronary disease, they have a grim prognosis. In 2008, the Food and Drug Association mandated the evidence of CV safety in any new diabetic therapy, leading to a multitude of large CV outcome trials to assess CV risk from these medications. However, several of these outcome trials with novel antidiabetic therapies have demonstrated not only safety but a clear and definite CV advantage in patients with type 2 diabetes. In this review, we discuss 2 relatively newer classes of diabetic drugs, sodium glucose cotransport 2 inhibitors and glucagon-like peptide 1 agonists, evaluate their efficacy in improving CV outcomes, and discuss the future of CV prevention with these agents.

New approach to diabetes care: from blood glucose to cardiovascular disease

Diabetes, a metabolic disease with vascular consequences due to accelerated atherosclerosis, is one of the 21st century's most prevalent chronic diseases. Characterized by inability to produce or use insulin, leading to hyperglycemia and insulin deficiency, diabetes causes a variety of microvascular (such as retinopathy and kidney disease) and macrovascular complications (including myocardial infarction and stroke) which reduce the quality of life and life expectancy of individuals with diabetes. We describe the close relationship between diabetes, cardiovascular risk factors, and cardiovascular disease, and examine multifactorial approaches to diabetes treatment, including reducing cardiovascular risk in individuals with type 2 diabetes. Finally, we analyze new prospects for the treatment of type 2 diabetes, resulting from the development of novel antidiabetic drugs. The aim of this review is that the clinician should assume the crucial role of guiding individuals with diabetes in the control of their disease, in order to improve their quality of life and prognosis. In view of the currently available evidence, the emergence of new glucose-reducing therapies with proven cardiovascular benefit means that the best therapeutic strategy for diabetes must go beyond reducing hyperglycemia and aim to reduce cardiovascular risk.

Liraglutide Treatment Reduces Endothelial Endoplasmic Reticulum Stress and Insulin Resistance in Patients With Diabetes Mellitus

Background Prior studies have shown that nutrient excess induces endoplasmic reticulum ( ER ) stress in nonvascular tissues from patients with diabetes mellitus ( DM ). ER stress and the subsequent unfolded protein response may be protective, but sustained activation may drive vascular injury. Whether ER stress contributes to endothelial dysfunction in patients with DM remains unknown. Methods and Results To characterize vascular ER stress, we isolated endothelial cells from 42 patients with DM and 37 subjects without DM. Endothelial cells from patients with DM displayed higher levels of ER stress markers compared with controls without DM. Both the early adaptive response, evidenced by higher phosphorylated protein kinase-like ER eukaryotic initiation factor-2a kinase and inositol-requiring ER-to-nucleus signaling protein 1 ( P=0.02, P=0.007, respectively), and the chronic ER stress response evidenced by higher C/ EBP α-homologous protein ( P=0.02), were activated in patients with DM . Higher inositol-requiring ER-to-nucleus signaling protein 1 activation was associated with lower flow-mediated dilation, consistent with endothelial dysfunction ( r=0.53, P=0.02). Acute treatment with liraglutide, a glucagon-like peptide 1 receptor agonist, reduced p-inositol-requiring ER-to-nucleus signaling protein 1 ( P=0.01), and the activation of its downstream target c-jun N-terminal kinase ( P=0.025) in endothelial cells from patients with DM . Furthermore, liraglutide restored insulin-stimulated endothelial nitric oxide synthase activation in patients with DM ( P=0.019). Conclusions In summary, our data suggest that ER stress contributes to vascular insulin resistance and endothelial dysfunction in patients with DM . Further, we have demonstrated that liraglutide ameliorates ER stress, decreases c-jun N-terminal kinase activation and restores insulin-mediated endothelial nitric oxide synthase activation in endothelial cells from patients with DM .

Glucagon-Like Peptide-1 Receptor Agonist Use and Renal Impairment: A Retrospective Analysis of an Electronic Health Records Database in the U.S. Population

INTRODUCTION

The study characterizes the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in patients with type 2 diabetes (T2D) with and without renal impairment and examines the effects of such use on the clinical outcomes of estimated glomerular filtration rate (eGFR) and glycated hemoglobin (A1c).

METHODS

Data from the Practice Fusion electronic health records database from 1 January 2012 through 30 April 2015 were used. Adults with T2D who received serum creatinine laboratory tests and initiated therapy with a GLP-1 RA (N = 3225) or other glucose-lowering agent (GLA) (N = 37,074) were included in the analysis. The GLP-1 RA cohort was matched to cohorts initiating therapy any other GLA, and multivariable analyses examined the association between GLP-1 RA use and changes in eGFR or A1c at 1 year after therapy initiation.

RESULTS

In this study, only 5.7% of patients with an eGFR of < 30 and ≥ 15 mL/min/1.73 m² and 3.6% of patients with an eGFR of  < 15 mL/min/1.73 m² initiated therapy with a GLP-1 RA. Compared to other GLAs, at 1-year after initiation of therapy the use of a GLP-1 RA was associated with a significantly smaller decline in eGFR (- 0.80 vs. - 1.03 mL/min/1.73 m²; P = 0.0005), a significantly smaller likelihood of having a ≥ 30% reduction in eGFR (2.19 vs. 3.14%; P < 0.0001), and a significantly larger reduction in A1c (- 0.48 vs. - 0.43; P = 0.0064).

CONCLUSION

In clinical practice, the use of GLP-1 RAs in patients with a higher degree of renal impairment disease was limited. Compared to other GLAs, the use of GLP-1 RAs was associated with a significantly smaller decline in eGFR and a larger reduction in A1c over the 1 year following therapy initiation.

FUNDING

Eli Lilly and Company.

Long-Term Effectiveness of Liraglutide in Association with Patients' Baseline Characteristics in Real-Life Setting in Croatia: An Observational, Retrospective, Multicenter Study

INTRODUCTION

Glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) are recommended therapy for type 2 diabetes (T2DM) and liraglutide is the most used worldwide. We assessed the glycemic efficacy and extra-glycemic effects of liraglutide during 36 months' follow-up of individuals with poorly regulated T2DM under routine clinical practice and sought to identify the phenotype of treatment responders.

METHODS

A total of 207 individuals were included. The primary endpoint was the proportion of participants with HbA1c < 7.0% and/or weight reduction. Secondary endpoints included changes in lipids, blood pressure, fasting c-peptide, and antidiabetic treatment during follow-up of 3 years.

RESULTS

Liraglutide was prescribed to 89.8% of participants already on at least two antidiabetic medications and 18% on insulin. Subject's mean age was 53.28 ± 9.42 years with duration of diabetes 8.29 ± 4.89 years. Baseline HbA1c was 8.5 ± 1.3% and body mass index (BMI) was 39 ± 4.5 kg/m2. Reduction of HbA1c was observed in 84.4% of participants, and 89.2% experienced average weight reduction of 5 kg. A composite outcome (reduction of HbA1c with any weight loss) was achieved in 76.2% of patients. After 6 months on liraglutide treatment, 38.1% of participants achieved target HbA1c level < 7%. This effect was maintained for 36 months in 50.8% of subjects. Increase in c-peptide was evident after 24 months (p = 0.030). Participants experienced a significant reduction in systolic blood pressure (BP) (p = 0.003), while there was no effect on diastolic BP, lipid profile, or liver enzymes. The number of participants treated with sulfonylurea decreased from 60.8% to 17.5%, while the number treated with insulin and sodium-glucose co-transporter-2 (SGLT-2) inhibitor increased (17.6% to 24.6% and 2.5% to 36.8%, respectively). Independent predictors of durability of HbA1c reduction were initial BMI (p = 0.004), HbA1c (p < 0.001), systolic BP (p = 0.007), and cholesterol (p = 0.020). Moreover, female gender and shorter duration of diabetes were independent predictors for HbA1c reduction.

CONCLUSION

Liraglutide shows sustained glycemic and extra-glycemic effects when used for treatment of obese poorly regulated individuals with T2DM.

So Many Antihyperglycemics: How to Choose? A Practical Approach

Guidelines from around the world have stressed the importance of glycemic control in the management of patients with type 2 diabetes (T2DM) to reduce the risk of developing complications. To achieve this goal, both lifestyle and pharmacologic therapies are available. There are 9 classes of antihyperglycemic therapies available in Canada and each class provides a different mechanism of action to address the pathophysiology of T2DM. Metformin remains the first choice for pharmacologic therapy. Thereafter, individualization is essential. If there is significant hyperglycemia at diagnosis, initial combination therapy should be considered. The choice of therapy after metformin depends on a number of factors with the first consideration being the presence or absence of cardiovascular disease. If present, an agent with proven cardiovascular benefit should be added. Otherwise, individualization should be based on desired glycemic lowering, risk of hypoglycemia, effect on weight, cardiovascular effects, other side effects and accessibility.