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Jiang XY, Chen Q, Chen XY, Sun QY, Jing F, Zhang HQ, Xu J, Li XH, Guan QB. Superoxide dismutases: marker in predicting reduced left ventricular ejection fraction in patients with type 2 diabetes and acute coronary syndrome. BMC Cardiovasc Disord 2024; 24:191. [PMID: 38570824 PMCID: PMC10988854 DOI: 10.1186/s12872-024-03867-2] [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: 12/11/2023] [Accepted: 03/29/2024] [Indexed: 04/05/2024] Open
Abstract
AIM To examine the prognostic value of superoxide dismutase (SOD) activity for monitoring reduced left ventricular ejection fraction(LVEF)in the patients with type 2 diabetes and acute coronary syndrome (ACS). METHODS The population of this cross-sectional study included 2377 inpatients with type 2 diabetes who had an ACS admitted to the Shandong Provincial Hospital Affiliated to Shandong First Medical University from January 2016 to January 2021. RESULTS Diabetic patients with ACS were divided into 2 subgroups based on LVEF. The mean SOD activity was significantly lower in patients with an LVEF ≤ 45% than in those with an LVEF > 45% (149.1 (146.4, 151.9) versus 161.9 (160.8, 163.0)). Using ROC statistic, a cut-off value of 148.8 U/ml indicated an LVEF ≤ 45% with a sensitivity of 51.6% and a specificity of 73.7%. SODs activity were found to be correlated with the levels of NT-proBNP, hs-cTnT, the inflammatory marker CRP and fibrinogen. Despite taking the lowest quartile as a reference (OR 0.368, 95% CI 0.493-0.825, P = 0.001) or examining 1 normalized unit increase (OR 0.651, 95% CI 0.482-0.880, P = 0.005), SOD activity was found to be a stronger predictor of reduced LVEF than CRP and fibrinogen, independent of confounding factors. CONCLUSIONS Our cross-sectional study suggests that SOD activity might be a valuable and easily accessible tool for assessing and monitoring reduced LVEF in the diabetic patients with ACS.
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Affiliation(s)
- Xiu-Yun Jiang
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Qing Chen
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Xiao-Yu Chen
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Qiu-Ying Sun
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Fei Jing
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Hai-Qing Zhang
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Jin Xu
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Xiao-Hong Li
- International Medical Service Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China.
| | - Qing-Bo Guan
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
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Nicholls SJ, Bhatt DL, Buse JB, Prato SD, Kahn SE, Lincoff AM, McGuire DK, Nauck MA, Nissen SE, Sattar N, Zinman B, Zoungas S, Basile J, Bartee A, Miller D, Nishiyama H, Pavo I, Weerakkody G, Wiese RJ, D'Alessio D. Comparison of tirzepatide and dulaglutide on major adverse cardiovascular events in participants with type 2 diabetes and atherosclerotic cardiovascular disease: SURPASS-CVOT design and baseline characteristics. Am Heart J 2024; 267:1-11. [PMID: 37758044 DOI: 10.1016/j.ahj.2023.09.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/11/2023] [Accepted: 09/16/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Tirzepatide, a once-weekly GIP/GLP-1 receptor agonist, reduces blood glucose and body weight in people with type 2 diabetes. The cardiovascular (CV) safety and efficacy of tirzepatide have not been definitively assessed in a cardiovascular outcomes trial. METHODS Tirzepatide is being studied in a randomized, double-blind, active-controlled CV outcomes trial. People with type 2 diabetes aged ≥40 years, with established atherosclerotic CV disease, HbA1c ≥7% to ≤10.5%, and body mass index ≥25 kg/m2 were randomized 1:1 to once weekly subcutaneous injection of either tirzepatide up to 15 mg or dulaglutide 1.5 mg. The primary outcome is time to first occurrence of any major adverse cardiovascular event (MACE), defined as CV death, myocardial infarction, or stroke. The trial is event-driven and planned to continue until ≥1,615 participants experience an adjudication-confirmed component of MACE. The primary analysis is noninferiority for time to first MACE of tirzepatide vs dulaglutide by demonstrating an upper confidence limit <1.05, which will also confirm superiority vs a putative placebo, and also to determine whether tirzepatide produces a greater CV benefit than dulaglutide (superiority analysis). RESULTS Over 2 years, 13,299 people at 640 sites in 30 countries across all world regions were randomized. The mean age of randomized participants at baseline was 64.1 years, diabetes duration 14.7 years, HbA1c 8.4%, and BMI 32.6 kg/m2. Overall, 65.0% had coronary disease, of whom 47.3% reported prior myocardial infarction and 57.4% had prior coronary revascularization. 19.1% of participants had a prior stroke and 25.3% had peripheral artery disease. The trial is fully recruited and ongoing. CONCLUSION SURPASS-CVOT will provide definitive evidence as to the CV safety and efficacy of tirzepatide as compared with dulaglutide, a GLP-1 receptor agonist with established CV benefit.
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Affiliation(s)
- Stephen J Nicholls
- Victorian Heart Institute, Monash University, VIC, Melbourne, Australia.
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY
| | - John B Buse
- University of North Carolina, Chapel Hill, NC
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, Section of Metabolic Diseases and Diabetes, University of Pisa, Pisa, and Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Steven E Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington, Seattle, WA
| | - A Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research) and Department of Cardiovascular Medicine, Cleveland, OH
| | - Darren K McGuire
- University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX
| | - Michael A Nauck
- Diabetes, Endocrinology and Metabolism Section, Department of Medicine I, St. Josef-Hospital, Katholisches Klinikum Bochum gGmbH, Ruhr University of Bochum, Bochum, Germany
| | - Steven E Nissen
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research) and Department of Cardiovascular Medicine, Cleveland, OH
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom
| | - Bernard Zinman
- University of Toronto, Lunenfeld-Tanenbaum Research Institute and Mount Sinai Hospital, Toronto, ON, Canada
| | - Sophia Zoungas
- Victorian Heart Institute, Monash University, VIC, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia
| | - Jan Basile
- Medical University of South Carolina, Ralph H. Johnson VA Medical Center, Charleston, SC
| | | | | | | | - Imre Pavo
- Eli Lilly and Company, Indianapolis, IN
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3
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Chen TK, Hoenig MP, Nitsch D, Grams ME. Advances in the management of chronic kidney disease. BMJ 2023; 383:e074216. [PMID: 38052474 DOI: 10.1136/bmj-2022-074216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Chronic kidney disease (CKD) represents a global public health crisis, but awareness by patients and providers is poor. Defined as persistent abnormalities in kidney structure or function for more than three months, manifested as either low glomerular filtration rate or presence of a marker of kidney damage such as albuminuria, CKD can be identified through readily available blood and urine tests. Early recognition of CKD is crucial for harnessing major advances in staging, prognosis, and treatment. This review discusses the evidence behind the general principles of CKD management, such as blood pressure and glucose control, renin-angiotensin-aldosterone system blockade, statin therapy, and dietary management. It additionally describes individualized approaches to treatment based on risk of kidney failure and cause of CKD. Finally, it reviews novel classes of kidney protective agents including sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, non-steroidal selective mineralocorticoid receptor antagonists, and endothelin receptor antagonists. Appropriate, widespread implementation of these highly effective therapies should improve the lives of people with CKD and decrease the worldwide incidence of kidney failure.
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Affiliation(s)
- Teresa K Chen
- Kidney Health Research Collaborative and Division of Nephrology, Department of Medicine, University of California San Francisco; and San Francisco VA Health Care System, San Francisco, CA, USA
| | - Melanie P Hoenig
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Morgan E Grams
- Department of Medicine, New York University Langone School of Medicine, New York, NY, USA
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Khunti K, Almalki M, Chan JCN, Amod A. The Role of Real-World Evidence in Treatment Decision-Making, Regulatory Assessment, and Understanding the Perspectives of People with Type 2 Diabetes: Examples with Gliclazide MR. Diabetes Ther 2023; 14:1609-1625. [PMID: 37603144 PMCID: PMC10499769 DOI: 10.1007/s13300-023-01458-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/28/2023] [Indexed: 08/22/2023] Open
Abstract
Real-world evidence (RWE) plays an important role in the management of type 2 diabetes (T2D). It provides data about the effectiveness and safety of an intervention from outside the randomised controlled trial (RCT) setting and allows healthcare professionals (HCPs) to determine if RCT data are applicable to their patients in routine clinical practice. This review provides a discussion of the value of RWE in T2D management in day-to-day clinical practice, with a focus on RWE with sulfonylureas (SUs), and presents two examples of a new generation of international real-world studies in people with T2D managed in routine clinical practice. RWE plays a valuable role in advising HCPs in the day-to-day management of T2D, informing regulatory authorities with regard to pharmacovigilance and post-approval updates, and providing insights with regard to patients' treatment adherence and preference. RWE should be used alongside RCTs to increase HCP awareness and understanding of their patients' perspectives, potentially allowing for improvements in treatment adherence, glycaemic control and health-related quality of life (HRQoL). In addition, real-world studies must be conducted in a way that generates robust RWE by limiting the risks of bias and confounding as much as possible. A growing body of RWE is emerging from Asia. For example, in a preliminary HRQoL analysis of the Joint Asia Diabetes Evaluation (JADE) Register, Asian people with T2D had better HRQoL with gliclazide-based treatment than with other SU agents, despite being older and having more diabetes-related complications.
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Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, LE5 4PW, UK.
| | - Mussa Almalki
- King Fahad Medical City, Obesity, Endocrine and Metabolism Centre, Riyadh, Saudi Arabia
| | - Juliana C N Chan
- Department of Medicine and Therapeutics, Hong Kong Institute of Diabetes and Obesity and Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Aslam Amod
- Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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5
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Alharbe UA, Alatawi HH, Amirthalingam P, Daghriri SM, Alhwiti AA, Alenazi TS, Al Ahmare ATS, Zaitone SA, Aljabri A, Hamdan AM. Ethnicity affects the risk factors of acute myocardial infarction and should be considered in educational programs. Front Cardiovasc Med 2022; 9:948028. [PMID: 36337894 PMCID: PMC9626760 DOI: 10.3389/fcvm.2022.948028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/29/2022] [Indexed: 12/03/2022] Open
Abstract
Acute Myocardial infarction is a non-communicable disease representing the leading cause of death in Saudi Arabia. Studying the ethnicity in its risk factors has been poorly investigated.
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Affiliation(s)
| | - Hanad Hassan Alatawi
- Pharmaceutical Care Department, Almahrajan Primary Healthcare Centre, Ministry of Health, Tabuk, Saudi Arabia
| | | | | | | | - Tahani Saud Alenazi
- Department of Pharmacy Practice, Faculty of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | | | - Sawsan A. Zaitone
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Suez Canal University, Ismailia, Egypt
| | - Ahmed Aljabri
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmed Mohsen Hamdan
- Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
- *Correspondence: Ahmed Mohsen Hamdan
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Wolsk E, Claggett B, Diaz R, Dickstein K, Gerstein HC, Køber L, Lewis EF, Maggioni AP, McMurray JJV, Probstfield JL, Riddle MC, Solomon SD, Tardif JC, Pfeffer MA. Risk Estimates of Imminent Cardiovascular Death and Heart Failure Hospitalization Are Improved Using Serial Natriuretic Peptide Measurements in Patients With Coronary Artery Disease and Type 2 Diabetes. J Am Heart Assoc 2022; 11:e021327. [PMID: 35383463 PMCID: PMC9238457 DOI: 10.1161/jaha.121.021327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Baseline and temporal changes in natriuretic peptide (NP) concentrations have strong prognostic value with regard to long‐term cardiovascular risk stratification. To increase the clinical utility of NP sampling for patient management, we wanted to assess the incremental predictive value of 2 serial NP measurements compared with a single measurement and provide absolute risk estimates for cardiovascular death or heart failure hospitalization (HFH) within 6 months based on 2 serial NP measurements. Methods and Results Consecutive NP samples obtained from 5393 patients with a recent coronary event and type 2 diabetes enrolled in the ELIXA (Evaluation of Cardiovascular Outcomes in Patients With Type 2 Diabetes After Acute Coronary Syndrome During Treatment With Lixisenatide) trial were used to construct best logistic regression models with outcome of cardiovascular death or HFH (136 events). Absolute risk estimates of cardiovascular death or HFH within 6 months using either BNP (B‐type natriuretic peptide) or NT‐proBNP (N‐terminal pro‐BNP) serial measurements were depicted based on the concentrations of 2 serial NP measurements. During the 6‐month follow‐up periods, the incidence rate (±95% CIs) of cardiovascular death or HFH for patients was 14.0 (11.8‒16.6) per 1000 patient‐years. Risk prediction depended on NP concentrations from both prior and current sampling. NP sampling 6 months apart improved the predictive value and reclassification of patients compared with a single sample (AUROC [Area Under the Receiver Operating Characteristic curve]: BNP, P=0.003. NT‐proBNP, P<0.0001), with a majority of moderate‐risk patients (6‐month risk between 1% and 10%) being reclassified on the basis of the second NP sample. Conclusions Serial NP measurements improved prediction of imminent cardiovascular death or HFH in patients with coronary artery disease and type 2 diabetes. The absolute risk estimates provided may aid clinicians in decision‐making and help patients understand their short‐term risk profile.
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Affiliation(s)
- Emil Wolsk
- Division of Cardiovascular Medicine Brigham and Women's Hospital Harvard Medical School Boston MA.,Department of Cardiology Herlev-Gentofte Hospital Herlev Denmark
| | - Brian Claggett
- Division of Cardiovascular Medicine Brigham and Women's Hospital Harvard Medical School Boston MA
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica Rosario Argentina
| | | | - Hertzel C Gerstein
- Division of Endocrinology & Metabolism McMaster University Hamilton ON Canada
| | - Lars Køber
- Department of Cardiology Rigshospitalet Copenhagen Denmark
| | - Eldrin F Lewis
- Cardiovascular Medicine Department of Medicine Stanford University Stanford CA
| | - Aldo P Maggioni
- Research Center of the Italian Association of Hospital Cardiologists Florence Italy.,Maria Cecilia Hospital GVM Care & Research Cotignola RA Italy
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre University of Glasgow Glasgow United Kingdom
| | | | - Matthew C Riddle
- Division of Endocrinology Oregon Health and Science University Portland OR
| | - Scott D Solomon
- Division of Cardiovascular Medicine Brigham and Women's Hospital Harvard Medical School Boston MA
| | | | - Marc A Pfeffer
- Division of Cardiovascular Medicine Brigham and Women's Hospital Harvard Medical School Boston MA
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7
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Dardano A, Aragona M, Daniele G, Miccoli R, Del Prato S. Efficacy of Dulaglutide in a Patient With Type 2 Diabetes, High Cardiovascular Risk, and HIV: A Case Report. Front Endocrinol (Lausanne) 2022; 13:847778. [PMID: 35295985 PMCID: PMC8918572 DOI: 10.3389/fendo.2022.847778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/31/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Type 2 diabetes (T2D) is a common comorbidity in people living with HIV (PLWH). Anti-hyperglycemic treatment in PLWH is still a challenge, and no randomized controlled studies using new glucose-lowering agents are currently available. CASE DESCRIPTION A 55-year-old-women was admitted to our Diabetes Unit because of hyperosmolar hyperglycemic state (HHS) and sepsis. The medical history included HIV infection and insulin-treated diabetes. On clinical examination, the lady appeared dehydrated with dry buccal mucosa, tachycardia, altered mental status, genital infection, and fever. On admission, plasma glucose was 54.5 mmol/L, HbA1c 155 mmol/mol, osmolarity 389.4 mOsm/kg, bicarbonate 24.6 mmol/L with no detectable serum ketones. The patient was treated with i.v. fluid and insulin, and antibiotic therapy commenced. Upon HHS and sepsis resolution, a basal-bolus insulin therapy was implemented that was followed by significant improvement of daily glucose profiles and progressive reduction of insulin requirement until complete discontinuation. A low dose of metformin plus linagliptin was started. Since a severe atherosclerotic disease was diagnosed, a GLP-1 receptor agonist, dulaglutide, was added to metformin upon linagliptin withdrawal with maintenance of good glycemic control, treatment adherence and amelioration of quality of life and no side effects. CONCLUSION This case suggests that GLP-1 receptor agonist therapy may be effective and safe for treatment of T2D with high cardiovascular risk in PLWH, supporting the need of clinical trials directly assessing the safety and the efficacy of GLP-1 receptor agonist in these individuals.
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Affiliation(s)
- Angela Dardano
- Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
- *Correspondence: Angela Dardano,
| | - Michele Aragona
- Section of Metabolic Diseases & Diabetes, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giuseppe Daniele
- Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberto Miccoli
- Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Del Prato
- Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
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9
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Kanie T, Mizuno A, Takaoka Y, Suzuki T, Yoneoka D, Nishikawa Y, Tam WWS, Morze J, Rynkiewicz A, Xin Y, Wu O, Providencia R, Kwong JS. Dipeptidyl peptidase-4 inhibitors, glucagon-like peptide 1 receptor agonists and sodium-glucose co-transporter-2 inhibitors for people with cardiovascular disease: a network meta-analysis. Cochrane Database Syst Rev 2021; 10:CD013650. [PMID: 34693515 PMCID: PMC8812344 DOI: 10.1002/14651858.cd013650.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is a leading cause of death globally. Recently, dipeptidyl peptidase-4 inhibitors (DPP4i), glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose co-transporter-2 inhibitors (SGLT2i) were approved for treating people with type 2 diabetes mellitus. Although metformin remains the first-line pharmacotherapy for people with type 2 diabetes mellitus, a body of evidence has recently emerged indicating that DPP4i, GLP-1RA and SGLT2i may exert positive effects on patients with known CVD. OBJECTIVES To systematically review the available evidence on the benefits and harms of DPP4i, GLP-1RA, and SGLT2i in people with established CVD, using network meta-analysis. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and the Conference Proceedings Citation Index on 16 July 2020. We also searched clinical trials registers on 22 August 2020. We did not restrict by language or publication status. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) investigating DPP4i, GLP-1RA, or SGLT2i that included participants with established CVD. Outcome measures of interest were CVD mortality, fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, all-cause mortality, hospitalisation for heart failure (HF), and safety outcomes. DATA COLLECTION AND ANALYSIS Three review authors independently screened the results of searches to identify eligible studies and extracted study data. We used the GRADE approach to assess the certainty of the evidence. We conducted standard pairwise meta-analyses and network meta-analyses by pooling studies that we assessed to be of substantial homogeneity; subgroup and sensitivity analyses were also pursued to explore how study characteristics and potential effect modifiers could affect the robustness of our review findings. We analysed study data using the odds ratios (ORs) and log odds ratios (LORs) with their respective 95% confidence intervals (CIs) and credible intervals (Crls), where appropriate. We also performed narrative synthesis for included studies that were of substantial heterogeneity and that did not report quantitative data in a usable format, in order to discuss their individual findings and relevance to our review scope. MAIN RESULTS We included 31 studies (287 records), of which we pooled data from 20 studies (129,465 participants) for our meta-analysis. The majority of the included studies were at low risk of bias, using Cochrane's tool for assessing risk of bias. Among the 20 pooled studies, six investigated DPP4i, seven studied GLP-1RA, and the remaining seven trials evaluated SGLT2i. All outcome data described below were reported at the longest follow-up duration. 1. DPP4i versus placebo Our review suggests that DPP4i do not reduce any risk of efficacy outcomes: CVD mortality (OR 1.00, 95% CI 0.91 to 1.09; high-certainty evidence), myocardial infarction (OR 0.97, 95% CI 0.88 to 1.08; high-certainty evidence), stroke (OR 1.00, 95% CI 0.87 to 1.14; high-certainty evidence), and all-cause mortality (OR 1.03, 95% CI 0.96 to 1.11; high-certainty evidence). DPP4i probably do not reduce hospitalisation for HF (OR 0.99, 95% CI 0.80 to 1.23; moderate-certainty evidence). DPP4i may not increase the likelihood of worsening renal function (OR 1.08, 95% CI 0.88 to 1.33; low-certainty evidence) and probably do not increase the risk of bone fracture (OR 1.00, 95% CI 0.83 to 1.19; moderate-certainty evidence) or hypoglycaemia (OR 1.11, 95% CI 0.95 to 1.29; moderate-certainty evidence). They are likely to increase the risk of pancreatitis (OR 1.63, 95% CI 1.12 to 2.37; moderate-certainty evidence). 2. GLP-1RA versus placebo Our findings indicate that GLP-1RA reduce the risk of CV mortality (OR 0.87, 95% CI 0.79 to 0.95; high-certainty evidence), all-cause mortality (OR 0.88, 95% CI 0.82 to 0.95; high-certainty evidence), and stroke (OR 0.87, 95% CI 0.77 to 0.98; high-certainty evidence). GLP-1RA probably do not reduce the risk of myocardial infarction (OR 0.89, 95% CI 0.78 to 1.01; moderate-certainty evidence), and hospitalisation for HF (OR 0.95, 95% CI 0.85 to 1.06; high-certainty evidence). GLP-1RA may reduce the risk of worsening renal function (OR 0.61, 95% CI 0.44 to 0.84; low-certainty evidence), but may have no impact on pancreatitis (OR 0.96, 95% CI 0.68 to 1.35; low-certainty evidence). We are uncertain about the effect of GLP-1RA on hypoglycaemia and bone fractures. 3. SGLT2i versus placebo This review shows that SGLT2i probably reduce the risk of CV mortality (OR 0.82, 95% CI 0.70 to 0.95; moderate-certainty evidence), all-cause mortality (OR 0.84, 95% CI 0.74 to 0.96; moderate-certainty evidence), and reduce the risk of HF hospitalisation (OR 0.65, 95% CI 0.59 to 0.71; high-certainty evidence); they do not reduce the risk of myocardial infarction (OR 0.97, 95% CI 0.84 to 1.12; high-certainty evidence) and probably do not reduce the risk of stroke (OR 1.12, 95% CI 0.92 to 1.36; moderate-certainty evidence). In terms of treatment safety, SGLT2i probably reduce the incidence of worsening renal function (OR 0.59, 95% CI 0.43 to 0.82; moderate-certainty evidence), and probably have no effect on hypoglycaemia (OR 0.90, 95% CI 0.75 to 1.07; moderate-certainty evidence) or bone fracture (OR 1.02, 95% CI 0.88 to 1.18; high-certainty evidence), and may have no impact on pancreatitis (OR 0.85, 95% CI 0.39 to 1.86; low-certainty evidence). 4. Network meta-analysis Because we failed to identify direct comparisons between each class of the agents, findings from our network meta-analysis provided limited novel insights. Almost all findings from our network meta-analysis agree with those from the standard meta-analysis. GLP-1RA may not reduce the risk of stroke compared with placebo (OR 0.87, 95% CrI 0.75 to 1.0; moderate-certainty evidence), which showed similar odds estimates and wider 95% Crl compared with standard pairwise meta-analysis. Indirect estimates also supported comparison across all three classes. SGLT2i was ranked the best for CVD and all-cause mortality. AUTHORS' CONCLUSIONS Findings from both standard and network meta-analyses of moderate- to high-certainty evidence suggest that GLP-1RA and SGLT2i are likely to reduce the risk of CVD mortality and all-cause mortality in people with established CVD; high-certainty evidence demonstrates that treatment with SGLT2i reduce the risk of hospitalisation for HF, while moderate-certainty evidence likely supports the use of GLP-1RA to reduce fatal and non-fatal stroke. Future studies conducted in the non-diabetic CVD population will reveal the mechanisms behind how these agents improve clinical outcomes irrespective of their glucose-lowering effects.
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Affiliation(s)
- Takayoshi Kanie
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Atsushi Mizuno
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
- Penn Medicine Nudge Unit, University of Pennsylvania Philadelphia, Philadelphia, PA, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Yoshimitsu Takaoka
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Takahiro Suzuki
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Daisuke Yoneoka
- Division of Biostatistics and Bioinformatics, Graduate School of Public Health, St. Luke's International University, Tokyo, Japan
| | - Yuri Nishikawa
- Department of Gerontological Nursing and Healthcare Systems Management, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Gerontological Nursing, Kyorin University, Tokyo, Japan
| | - Wilson Wai San Tam
- Alice Lee Center for Nursing Studies, NUS Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Jakub Morze
- Department of Human Nutrition, University of Warmia and Mazury, Olsztyn, Poland
| | - Andrzej Rynkiewicz
- Department of Cardiology and Cardiosurgery, School of Medicine, University of Warmia and Mazury, Olsztyn, Poland
| | - Yiqiao Xin
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Rui Providencia
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
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10
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Melo M, Gavina C, Silva-Nunes J, Andrade L, Carvalho D. Heterogeneity amongst GLP-1 RA cardiovascular outcome trials results: can definition of established cardiovascular disease be the missing link? Diabetol Metab Syndr 2021; 13:81. [PMID: 34315528 PMCID: PMC8317280 DOI: 10.1186/s13098-021-00698-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/09/2021] [Indexed: 11/10/2022] Open
Abstract
Atherosclerotic cardiovascular diseases are the leading cause of adverse outcomes in patients with type 2 diabetes, and all new anti-diabetic agents are mandated to undergo cardiovascular outcome trials (CVOTs). Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are incretin mimetics that reduce blood glucose levels with a low associated risk of hypoglycaemia. CVOTs with different GLP-1 RAs yielded different results in terms of major cardiovascular composite outcome (MACE), with some trials showing superiority in the treatment arm, whereas other simply displayed non-inferiority. More importantly, the significance of each component of MACE varied between drugs. This begs the question of whether these differences are due to dissimilarities between drugs or other factors, namely trial design, are at the root of these differences. We analyse the trial designs for all CVOTs with GLP-1 RAs and highlight important differences between them, namely in terms of definition of established cardiovascular disease, and discuss how these differences might explain the disparate results of the trials and preclude direct comparisons between them. We conclude that a fair comparison between GLP-1 RA CVOTs would involve post-hoc analysis re-grouping the patients into different cardiovascular risk categories based upon their baseline clinical parameters, in order to even out the criteria used to classify patients.
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Affiliation(s)
- Miguel Melo
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Praceta, R. Prof. Mota Pinto, 3004-561, Coimbra, Portugal.
- Faculty of Medicine, Universidade de Coimbra, Coimbra, Portugal.
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar E Universitário S. João, Porto, Portugal.
| | - Cristina Gavina
- Cardiology Department, Hospital Pedro Hispano-ULS Matosinhos, Matosinhos, Portugal
- Cardiovascular Research and Development Unit, Faculty of Medicine, Universidade do Porto, Porto, Portugal
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar E Universitário S. João, Porto, Portugal
| | - José Silva-Nunes
- Department of Endocrinology, Diabetes, and Metabolism, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal
- NOVA Medical School / Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
- Health and Technology Research Center (H&TRC), Escola Superior de Tecnologia da Saúde de Lisboa, Lisboa, Portugal
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar E Universitário S. João, Porto, Portugal
| | - Luís Andrade
- Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar E Universitário S. João, Porto, Portugal
| | - Davide Carvalho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar E Universitário S. João, Porto, Portugal
- Faculty of Medicine, Universidade do Porto, Porto, Portugal
- i3SInstituto de Investigação e Inovação Em Saúde, Universidade do Porto, Porto, Portugal
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11
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Mosenzon O, Schechter M, Leibowitz G. Kidney Outcomes With Glucagon-Like Peptide-1 Receptor Agonists in Patients With Type 2 Diabetes. Adv Chronic Kidney Dis 2021; 28:347-360. [PMID: 34922691 DOI: 10.1053/j.ackd.2021.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/14/2021] [Accepted: 04/23/2021] [Indexed: 01/10/2023]
Abstract
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are highly effective in reducing glycemia in patients with type 2 diabetes (T2D). These medications effectively reduce cardiovascular (CV) risk in patients with T2D and established CV disease or with multiple risk factors. In addition, treatment with GLP-1 RA may exert protective effects on the diabetic kidney. Herein, we summarize the findings regarding the kidney safety and efficacy of GLP-1 RAs in patients with T2D. We review data from GLP-1 RAs phase 3 kidney studies, CV outcome trials, as well as real-world evidence. The accumulating data show that treatment with GLP-1 RAs is safe, well-tolerated, and effective in patients with different levels of kidney dysfunction. Furthermore, CV outcome trials suggest that GLP-1 RAs reduce albuminuria and may attenuate the decline in kidney function over time. The ongoing FLOW trial studying the effects of semaglutide in patients with diabetic kidney disease is expected to shed light on the effects of GLP-1 RAs on kidney outcomes and clarify their role in the management of patients with T2D and kidney disease.
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12
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Fuentes B, Amaro S, Alonso de Leciñana M, Arenillas J, Ayo-Martín O, Castellanos M, Freijo M, García-Pastor, Gomis M, Gómez Choco M, López-Cancio E, Martínez Sánchez P, Morales A, Palacio-Portilla E, Rodríguez-Yáñez M, Roquer J, Segura T, Serena J, Vivancos-Mora J. Stroke prevention in patients with type 2 diabetes mellitus or prediabetes: recommendations of the Spanish Society of Neurology’s Stroke Study Group. NEUROLOGÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.nrleng.2020.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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13
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Kadowaki T, Yamamoto F, Taneda Y, Naito Y, Clark D, Lund SS, Okamura T, Kaku K. Effects of anti-diabetes medications on cardiovascular and kidney outcomes in Asian patients with type 2 diabetes: a rapid evidence assessment and narrative synthesis. Expert Opin Drug Saf 2021; 20:707-720. [PMID: 33706621 DOI: 10.1080/14740338.2021.1898585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The cardiovascular and kidney safety of glucose-lowering drugs is a key concern in type 2 diabetes (T2D). We evaluated cardiorenal outcomes with glucose-lowering drugs in Asian patients, who comprise over half of T2D cases globally. RESEARCH DESIGN AND METHODS A rapid evidence assessment was conducted for phase III or IV, double-blind, randomized clinical trials of glucose-lowering drugs reporting cardiovascular or kidney outcomes for Asian T2D patients (Embase, Medline, Cochrane Library databases: 1 January 2008-14 June 2020). RESULTS Fifty-four publications reported exploratory data for Asians from 18 trials of dipeptidyl peptidase-4 (DPP-4) inhibitors, sodium-glucose co-transporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and insulin analogs. SGLT2 inhibitors and several GLP-1 receptor agonists were associated with reduced cardiovascular risk in Asian T2D patients, while DPP-4 inhibitors exhibited cardiovascular safety. SGLT2 inhibitors also appeared to reduce renal risk; however, kidney outcomes were lacking for DPP-4 inhibitors other than linagliptin and GLP-1 receptor agonists in Asian patients. Insulin data were inconclusive as the only trial conducted used different types of insulin as both treatment and comparator. CONCLUSIONS Cardiorenal outcomes with glucose-lowering drugs in Asian T2D patients were similar to outcomes in the overall multinational cohorts of these trials. DPP-4 inhibitors appear to demonstrate cardiovascular safety in Asians, while SGLT2 inhibitors and some GLP-1 receptor agonists may reduce cardiorenal and cardiovascular risk, respectively.
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Affiliation(s)
| | - Fumiko Yamamoto
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Yusuke Taneda
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Yusuke Naito
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Douglas Clark
- TA CardioMetabolism Respiratory Med, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Søren S Lund
- TA CardioMetabolism Respiratory Med, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Tomoo Okamura
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Kohei Kaku
- General Internal Medicine, Kawasaki Medical School, Okayama, Japan.,Faculty of Health and Welfare Services Management, Kawasaki University of Medical Welfare, Okayama, Japan
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14
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Pantalone KM, Munir K, Hasenour CM, Atisso CM, Varnado OJ, Maldonado JM, Konig M. Cardiovascular outcomes trials with glucagon-like peptide-1 receptor agonists: A comparison of study designs, populations and results. Diabetes Obes Metab 2020; 22:2209-2226. [PMID: 32744372 PMCID: PMC7754368 DOI: 10.1111/dom.14165] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/20/2020] [Accepted: 07/29/2020] [Indexed: 12/19/2022]
Abstract
Despite treatment advances leading to improved outcomes over the past 2 decades, cardiovascular (CV) disease (CVD) remains the leading cause of morbidity and mortality in people with diabetes. People with type 2 diabetes (T2D) have a 2- to 4-fold increased risk of CVD and CV death. Individuals with T2D have not seen the same improvements in CV morbidity and mortality as those without T2D. Given this, it is important to understand the CV impact of drugs used to treat T2D. In patients with T2D, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have shown a reduction in HbA1c and body weight regardless of their differences in chemical structure and pharmacokinetic variables. Glycaemic efficacy, accompanied by the potential for weight reduction and a low risk of hypoglycaemia, has moved GLP-1 RAs to the first treatment of choice following metformin monotherapy in the latest American Diabetes Association treatment guidelines. Additionally, all GLP-1 RAs have shown CV safety and several have proven CV benefit. GLP-1 RAs have been evaluated in cardiovascular outcomes trials (CVOTs) of varying sizes, designs and patient populations with differing reported effects on CV outcomes. The purpose of this article is to review the completed GLP-1 RA CVOTs with special attention to how their design, size, patient populations and conduct may influence the interpretation of results.
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Affiliation(s)
| | - Kashif Munir
- Center for Diabetes and EndocrinologyUniversity of MarylandBaltimoreMaryland
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15
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Wijkman MO, Claggett B, Diaz R, Gerstein HC, Køber L, Lewis E, Maggioni AP, Wolsk E, Aguilar D, Bentley-Lewis R, McMurray JJ, Probstfield J, Riddle M, Tardif JC, Solomon SD, Pfeffer MA. Blood pressure and mortality in patients with type 2 diabetes and a recent coronary event in the ELIXA trial. Cardiovasc Diabetol 2020; 19:175. [PMID: 33046070 PMCID: PMC7552471 DOI: 10.1186/s12933-020-01150-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/01/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The relationship between blood pressure and mortality in type 2 diabetes (T2DM) is controversial, with concern for increased risk associated with excessively lowered blood pressure. METHODS We evaluated whether prior cardiovascular disease (CVD) altered the relationship between baseline blood pressure and all-cause mortality in 5852 patients with T2DM and a recent acute coronary syndrome (ACS) who participated in the ELIXA (Evaluation of Lixisenatide in Acute Coronary Syndrome) trial. Risk of death was assessed in Cox models adjusted for age, sex, race, heart rate, BMI, smoking, diabetes duration, insulin use, HbA1c, eGFR, brain natriuretic peptide (BNP), urine albumin/creatinine ratio, treatment allocation and prior coronary revascularization. RESULTS Although overall there was no significant association between systolic blood pressure (SBP) and mortality (hazard ratio per 10 mmHg lower SBP 1.05 (95% CI 0.99-1.12) P = 0.10), lower SBP was significantly associated with higher risk of death (hazard ratio per 10 mmHg lower SBP 1.13 (95% CI 1.04-1.22) P = 0.002) in 2325 patients with additional CVD (index ACS+ at least one of the following prior to randomization: myocardial infarction other than the index ACS, stroke or heart failure). In 3527 patients with only the index ACS no significant association was observed (hazard ratio per 10 mmHg lower SBP 0.95 (0.86-1.04) P = 0.26; P for interaction 0.005). CONCLUSIONS The association between blood pressure and mortality was modified by additional CVD history in patients with type 2 diabetes and a recent coronary event. When blood pressures measured after an acute coronary event are used to assess the risk of death in patients with type 2 diabetes, the cardiovascular history needs to be taken into consideration. Trial registration ClinicalTrials.gov number NCT01147250, first posted June 22, 2010.
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Affiliation(s)
- Magnus O Wijkman
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA. .,Department of Internal Medicine and Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden.
| | - Brian Claggett
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Hertzel C Gerstein
- The Population Health Research Institute and the Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, Canada
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Eldrin Lewis
- Stanford University Medical Center, Stanford, USA
| | - Aldo P Maggioni
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy.,Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy
| | - Emil Wolsk
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - David Aguilar
- McGovern Medical School, University of Texas, Houston, USA
| | | | - John J McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | | | | | - Scott D Solomon
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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16
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Sachinidis A, Nikolic D, Stoian AP, Papanas N, Tarar O, Rizvi AA, Rizzo M. Cardiovascular outcomes trials with incretin-based medications: a critical review of data available on GLP-1 receptor agonists and DPP-4 inhibitors. Metabolism 2020; 111:154343. [PMID: 32810485 DOI: 10.1016/j.metabol.2020.154343] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 08/06/2020] [Accepted: 08/08/2020] [Indexed: 12/11/2022]
Abstract
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) and dipeptidyl peptidase-4 (DPP-4) inhibitors are so called "incretin-based therapies" (IBTs) that represent innovative therapeutic approaches and are commonly used in clinical practice for the treatment of type 2 diabetes mellitus (T2DM). The cardiovascular outcome trials (CVOTs) have provided useful information that has helped to shape changes in clinical practice guidelines for the management of T2DM. At the same time, the mechanisms that may explain the nonglycemic and cardiovascular (CV) benefits of these medications are still being explored. A summary of the main findings from CVOTs performed to-date with particular emphasis on various outcomes and inconsistencies observed in the trials is provided. Overall, available data is favourable to the early deployment of GLP-1RAs in clinical practice, fully in line with recommendations from international scientific guidelines, and based on their effects on glucose metabolism parameters, body weight reduction and CV outcomes. Evidence further suggest that the CV benefits of GLP-1RAs may not be a class effect, with GLP-1 analogues having a greater benefit rather than exendin-based agents.
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Affiliation(s)
- Alexandros Sachinidis
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy; 2nd Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dragana Nikolic
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy.
| | - Anca Pantea Stoian
- Department of Diabetes, Nutrition and Metabolic Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Omer Tarar
- Division of Endocrinology, Diabetes and Metabolism, School of Medicine, University of South Carolina, USA
| | - Ali A Rizvi
- Division of Endocrinology, Diabetes and Metabolism, School of Medicine, University of South Carolina, USA; Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA, USA
| | - Manfredi Rizzo
- Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy; Division of Endocrinology, Diabetes and Metabolism, School of Medicine, University of South Carolina, USA
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17
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Stroke prevention in patients with type 2 diabetes or prediabetes. Recommendations from the Cerebrovascular Diseases Study Group, Spanish Society of Neurology. Neurologia 2020; 36:305-323. [PMID: 32981775 DOI: 10.1016/j.nrl.2020.04.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/15/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To update the Spanish Society of Neurology's guidelines for stroke prevention in patients with type 2 diabetes or prediabetes, analysing the available evidence on the effect of metabolic control and the potential benefit of antidiabetic drugs with known vascular benefits in addition to conventional antidiabetic treatments in stroke prevention. DEVELOPMENT PICO-type questions (Patient, Intervention, Comparison, Outcome) were developed to identify practical issues in the management of stroke patients and to establish specific recommendations for each of them. Subsequently, we conducted systematic reviews of the PubMed database and selected those randomised clinical trials evaluating stroke as an independent variable (primary or secondary). Finally, for each of the PICO questions we developed a meta-analysis to support the final recommendations. CONCLUSIONS While there is no evidence that metabolic control reduces the risk of stroke, some families of antidiabetic drugs with vascular benefits have been shown to reduce these effects when added to conventional treatments, both in the field of primary prevention in patients presenting type 2 diabetes and high vascular risk or established atherosclerosis (GLP-1 agonists) and in secondary stroke prevention in patients with type 2 diabetes or prediabetes (pioglitazone).
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18
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Chawla R, Madhu SV, Makkar BM, Ghosh S, Saboo B, Kalra S. RSSDI-ESI Clinical Practice Recommendations for the Management
of Type 2 Diabetes Mellitus 2020. Int J Diabetes Dev Ctries 2020. [PMCID: PMC7371966 DOI: 10.1007/s13410-020-00819-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Rajeev Chawla
- North Delhi Diabetes Centre Rohini, New Delhi, India
| | - S. V. Madhu
- Centre for Diabetes, Endocrinology & Metabolism, UCMS-GTB Hospital, Delhi, India
| | - B. M. Makkar
- Dr Makkar’s Diabetes & Obesity Centre Paschim Vihar, New Delhi, India
| | - Sujoy Ghosh
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education & Research, Kolkata, West Bengal India
| | - Banshi Saboo
- DiaCare - A Complete Diabetes Care Centre, Ahmedabad, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana India
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19
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Yan C, Thijs L, Cao Y, Trenson S, Zhang ZY, Janssens S, Staessen JA, Feng YM. Opportunities of Antidiabetic Drugs in Cardiovascular Medicine: A Meta-Analysis and Perspectives for Trial Design. HYPERTENSION (DALLAS, TEX. : 1979) 2020; 76:420-431. [PMID: 32639887 DOI: 10.1161/hypertensionaha.120.14791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To identify potential application of GLP1-RAs (glucagon-like peptide-1 receptor agonists) and SGLT2-Is (sodium-dependent glucose cotrasnsporter-2 inhibitors) in cardiovascular medicine, we performed PubMed search until March 31, 2020 and selected placebo-controlled randomized trials (RCTs) in patients with type 2 diabetes mellitus. Twenty-four hour ambulatory and office blood pressure (BP), major adverse cardiovascular events (MACE), progression of chronic kidney disease (CKD), and changes in glycated hemoglobin and body weight were aggregated across RCTs using random-effect models. In 2238 patients (7 RCTs), SGLT2-Is lowered 24-hour systolic/diastolic BP by 4.4/1.9 mm Hg (95% CI, 3.4-5.5/1.2-2.6 mm Hg), whereas 2 GLP1-RAs RCTs produced contradictory BP results. Over 1.3 to 5.4 years of follow-up of 56 004 patients (7 RCTs), aggregate hazard ratios associated with GLP1-RA treatment were 0.88 (0.84-0.93) for MACE, 0.84 (0.74-0.89) for CKD, and ranged from 0.84 to 0.90 for individual MACE end points (P≤0.01). Across 5 SGLT2-Is RCTs, including 43 467 patients with 1.5 to 4.2 years follow-up, hazard ratios were 0.87 (0.82-0.93) for MACE, 0.68 (0.62-0.75) for HF, 0.82 (0.72-0.93) for cardiovascular death, 0.87 (0.79-0.96) for myocardial infarction, and 0.61 (0.56-0.67) for worsening CKD. The risk of HF and CKD, but not MACE, decreased with more BP lowering. Stricter glycemic control was associated with higher HF risk, but unrelated to MACE or CKD. The aggregate effect sizes on systolic BP, body weight, and glycated hemoglobin were -1.61 mm Hg, -2.40 kg, and -0.69% for GLP1-RAs, and -2.53 mm Hg, -1.15 kg and -0.24%, for SGLT2-Is (P<0.001). In conclusion, GLP1-RAs and SGLT2-Is reduced cardiovascular risk with differential benefit profiles.
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Affiliation(s)
- Cen Yan
- From the Department of Science and Technology, Beijing YouAn Hospital (C.Y., Y.-M.F.), Capital Medical University, China
| | - Lutgarde Thijs
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (L.T., Z.-Y.Z., J.A.S.)
| | - Yu Cao
- Center for Evidenced-Based Medicine, Beijing Luhe Hospital (Y.C.), Capital Medical University, China
| | - Sander Trenson
- Division of Cardiology, University Hospitals Leuven, Belgium (S.T., S.J.)
| | - Zhen-Yu Zhang
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (L.T., Z.-Y.Z., J.A.S.)
| | - Stefan Janssens
- Division of Cardiology, University Hospitals Leuven, Belgium (S.T., S.J.)
| | - Jan A Staessen
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium (L.T., Z.-Y.Z., J.A.S.).,Division of Cardiology, University Hospital Zürich, Switzerland (S.T.).,NPO Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (J.A.S.)
| | - Ying-Mei Feng
- From the Department of Science and Technology, Beijing YouAn Hospital (C.Y., Y.-M.F.), Capital Medical University, China
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20
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Jain R, Awal H, Sen S. Using adult stem cells to monitor endothelial dysfunction in diabetes mellitus. J Diabetes Complications 2020; 34:107588. [PMID: 32345465 DOI: 10.1016/j.jdiacomp.2020.107588] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/07/2020] [Accepted: 04/07/2020] [Indexed: 12/24/2022]
Abstract
Diabetes affects approximately 10.5% of adults in the United States and this is projected to nearly double by 2025. Both type 2 diabetes (T2DM) and obesity are associated with endothelial dysfunction, oxidative stress, endothelial cell inflammation, cardiovascular pro-thrombotic states and are the most common causes of endothelial dysfunction, chronic kidney disease (CKD) and cardiovascular disease (CVD). Lately several new diabetes medications have come to clinical use that claim CVD risk improvement, however modalities used to test and monitor CVD risk are not cell based, which bring into question the reproducibility of these studies. Our review is designed to highlight cardiovascular risk reduction with novel diabetes medications while emphasizing cellular outcomes as a biomarker of cardiovascular risk. We are going to highlight studies that comment on peripheral blood derived CD34+ hematopoietic progenitor cells, as biomarkers of endothelial function. CD34+ cells have been extensively investigated by us and several other laboratories for the last two decades, as a viable cardiovascular function biomarker. In this context we will also discuss relevant CVD risk reduction trials that used novel diabetes medications.
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Affiliation(s)
- Rohit Jain
- Division of Endocrinology, Department of Medicine, The George Washington University, Washington, DC, USA
| | - Hassan Awal
- Division of Endocrinology, Department of Medicine, The George Washington University, Washington, DC, USA
| | - Sabyasachi Sen
- Division of Endocrinology, Department of Medicine, The George Washington University, Washington, DC, USA.
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21
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Das AK, Mithal A, Kumar KMP, Unnikrishnan AG, Kalra S, Thacker H, Sethi B, Ghosh R, Mathew A, Chodankar D, Mohanasundaram S, Menon SK, Trivedi C, Naqvi M, Kanade V, Salvi V, Chatterjee G, Rais N, Wangnoo SK, Chowdhury S, Zargar AH, Joshi S. Rationale, study design and methodology of the LANDMARC trial: a 3-year, pan-India, prospective, longitudinal study to assess management and real-world outcomes of diabetes mellitus. Diabet Med 2020; 37:885-892. [PMID: 31691356 PMCID: PMC7216981 DOI: 10.1111/dme.14171] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2019] [Indexed: 11/30/2022]
Abstract
AIM India contributes towards a large part of the worldwide epidemic of diabetes and its associated complications. However, there are limited longitudinal studies available in India to understand the occurrence of diabetes complications over time. This pan-India longitudinal study was initiated to assess the real-world outcomes of diabetes across the country. METHODS The LANDMARC study is the first prospective, multicentre, longitudinal, observational study investigating a large cohort of people with type 2 diabetes mellitus across India over a period of 3 years. The primary objective of this ongoing study is to determine the proportion of people developing macrovascular diabetes complications over the duration of the study (36 months ± 45 days) distributed over seven visits; the secondary objective is to evaluate microvascular diabetes complications, glycaemic control and time-to-treatment adaptation or intensification. Overall, 6300 participants (aged 25-60 years) diagnosed with type 2 diabetes for at least 2 years will be included from 450 centres across India. Data will be recorded for baseline demographics, comorbidities, glycaemic measurements, use of anti-hyperglycaemic medications and any cardiovascular or other diabetes-related events occurring during the observational study period. CONCLUSIONS The LANDMARC study is expected to reveal the trends in complications associated with diabetes, treatment strategies used by physicians, and correlation among treatment, control and complications of diabetes within the Indian context. The findings of this study will help to identify the disease burden, emergence of early-onset complications and dose titration patterns, and eventually develop person-centred care and facilitate public health agencies to invest appropriate resources in the management of diabetes. (Trial Registration No: CTRI/2017/05/008452).
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Affiliation(s)
- A. K. Das
- Pondicherry Institute of Medical Sciences (PIMS)PuducherryIndia
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- Chowpatti Medical CentreMumbaiIndia
| | - S. K. Wangnoo
- Apollo Hospital Education and Research FoundationNew DelhiIndia
| | | | - A. H. Zargar
- Center for Diabetes & Endocrine CareSrinagarIndia
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22
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Patti AM, Rizvi AA, Giglio RV, Stoian AP, Ligi D, Mannello F. Impact of Glucose-Lowering Medications on Cardiovascular and Metabolic Risk in Type 2 Diabetes. J Clin Med 2020; 9:jcm9040912. [PMID: 32225082 PMCID: PMC7230245 DOI: 10.3390/jcm9040912] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023] Open
Abstract
Type 2 Diabetes Mellitus (T2DM) is associated with a high risk of atherosclerotic cardiovascular (CV) disease. Among the well-known pathophysiologic factors, crucial roles are played by endothelial dysfunction (caused by oxidative stress and inflammation hyperglycemia-linked), increased activity of nuclear factor kB, altered macrophage polarization, and reduced synthesis of resident endothelial progenitor cells. As consequence, a potentially rapid progression of the atherosclerotic disease with a higher propensity to unstable plaque is arguable, finally leading to significantly increased cardiovascular mortality. Main managements are focused on both prevention and early diagnosis, by targeted treatment of hyperglycemia and vascular complications. Innovative therapeutic approaches for T2DM seek to customize the antidiabetic treatment to each patient in order to optimize glucose-lowering effects, minimize hypoglycemia and adverse effects, and prevent cardiovascular events. The newer drugs (e.g., Glucagon Like Peptide-1 Receptor Agonists, GLP-1 RAs; Sodium GLucose coTransporter-2 inhibitors, SGLT2is; DiPeptidyl Peptidase-4 inhibitors, and DPP4is) impact body weight, lipid parameters, and blood pressure, as well as endothelial (dys)functions, inflammatory markers, biomarkers of both oxidative stress, and subclinical atherosclerosis. The present review summarizes the results of the main trials focused on the cardiovascular safety of these drugs from the CV standpoint.
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Affiliation(s)
- Angelo Maria Patti
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), School of Medicine, University of Palermo, 90121 Palermo, Italy;
- Correspondence: (A.M.P.); (F.M.)
| | - Ali A Rizvi
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA;
| | - Rosaria Vincenza Giglio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), School of Medicine, University of Palermo, 90121 Palermo, Italy;
| | - Anca Pantea Stoian
- Faculty of General Medicine, Diabetes, Nutrition and Metabolic Diseases Department, Carol Davila University, 050474 Bucharest, Romania;
| | - Daniela Ligi
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, University Carlo Bo of Urbino, 61029 Urbino, Italy;
| | - Ferdinando Mannello
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, University Carlo Bo of Urbino, 61029 Urbino, Italy;
- Correspondence: (A.M.P.); (F.M.)
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23
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Shin S, Claggett B, Pfeffer MA, Skali H, Liu J, Aguilar D, Diaz R, Dickstein K, Gerstein HC, Køber LV, Lawson FC, Lewis EF, Maggioni AP, McMurray JJ, Probstfield JL, Riddle MC, Tardif J, Solomon SD. Hyperglycaemia, ejection fraction and the risk of heart failure or cardiovascular death in patients with type 2 diabetes and a recent acute coronary syndrome. Eur J Heart Fail 2020; 22:1133-1143. [DOI: 10.1002/ejhf.1790] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 02/20/2020] [Accepted: 02/22/2020] [Indexed: 12/25/2022] Open
Affiliation(s)
- Sung‐Hee Shin
- Cardiovascular Division Brigham and Women's Hospital, and Harvard Medical School Boston MA USA
- Inha University Incheon South Korea
| | - Brian Claggett
- Cardiovascular Division Brigham and Women's Hospital, and Harvard Medical School Boston MA USA
| | - Marc A. Pfeffer
- Cardiovascular Division Brigham and Women's Hospital, and Harvard Medical School Boston MA USA
| | | | - Jiankang Liu
- Cardiovascular Division Brigham and Women's Hospital, and Harvard Medical School Boston MA USA
| | - David Aguilar
- University of Texas Health Science Center Houston TX USA
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica Rosario Argentina
| | - Kenneth Dickstein
- University of Bergen, Stavanger University Hospital Stavanger Norway
| | - Hertzel C. Gerstein
- Department of Medicine and Population Health Research Institute McMaster University and Hamilton Health Sciences Ontario Canada
| | - Lars V. Køber
- Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | | | - Eldrin F. Lewis
- Cardiovascular Division Brigham and Women's Hospital, and Harvard Medical School Boston MA USA
| | - Aldo P. Maggioni
- Research Center of the Italian Association of Hospital Cardiologists Florence Italy
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre University of Glasgow Glasgow UK
| | | | | | | | - Scott D. Solomon
- Cardiovascular Division Brigham and Women's Hospital, and Harvard Medical School Boston MA USA
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Chawla R, Madhu SV, Makkar BM, Ghosh S, Saboo B, Kalra S. RSSDI-ESI Clinical Practice Recommendations for the Management of Type 2 Diabetes Mellitus 2020. Indian J Endocrinol Metab 2020; 24:1-122. [PMID: 32699774 PMCID: PMC7328526 DOI: 10.4103/ijem.ijem_225_20] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Rajeev Chawla
- North Delhi Diabetes Centre, Rohini, New Delhi, India
| | - S. V. Madhu
- Centre for Diabetes, Endocrinology and Metabolism, UCMS-GTB Hospital, New Delhi, India
| | - B. M. Makkar
- Dr. Makkar's Diabetes and Obesity Centre, Paschim Vihar, New Delhi, India
| | - Sujoy Ghosh
- Department of Endocrinology and Metabolism, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Banshi Saboo
- DiaCare - A Complete Diabetes Care Centre, Ahmedabad, Gujarat, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
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Nolen-Doerr E, Stockman MC, Rizo I. Mechanism of Glucagon-Like Peptide 1 Improvements in Type 2 Diabetes Mellitus and Obesity. Curr Obes Rep 2019; 8:284-291. [PMID: 31124035 DOI: 10.1007/s13679-019-00350-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to emphasize the pivotal role of glucagon-like peptide 1 (GLP-1) in tackling the parallel epidemics of obesity and type 2 diabetes (T2DM). RECENT FINDINGS GLP-1-based therapies and in particular GLP-1 receptor agonists (GLP-1 RA) have proven to be effective in lowering blood glucose and decreasing weight. GLP-1 RA not only mitigate these significant medical burdens but also result in weight loss and weight loss independent factors that decrease cardiovascular disease (CVD) and microvascular complications of T2DM, such as diabetic nephropathy. GLP-1-based therapies are critical for a patient-centered approach in choosing appropriate pharmacotherapy for T2DM and obesity while also taking into consideration comorbidities, such as cardiovascular and chronic kidney diseases.
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Affiliation(s)
- Eric Nolen-Doerr
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Boston University School of Medicine and Boston Medical Center, 720 Harrison Avenue, Doctor's Office Building, Suite 8100, Boston, MA, 02118, USA.
| | - Mary-Catherine Stockman
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Boston University School of Medicine and Boston Medical Center, 720 Harrison Avenue, Doctor's Office Building, Suite 8100, Boston, MA, 02118, USA.
| | - Ivania Rizo
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Boston University School of Medicine and Boston Medical Center, 720 Harrison Avenue, Doctor's Office Building, Suite 8100, Boston, MA, 02118, USA.
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26
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Boye KS, Riddle MC, Gerstein HC, Mody R, Garcia‐Perez L, Karanikas CA, Lage MJ, Riesmeyer JS, Lakshmanan MC. Generalizability of glucagon-like peptide-1 receptor agonist cardiovascular outcome trials to the overall type 2 diabetes population in the United States. Diabetes Obes Metab 2019; 21:1299-1304. [PMID: 30714309 PMCID: PMC6593714 DOI: 10.1111/dom.13649] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 01/25/2019] [Accepted: 02/01/2019] [Indexed: 12/29/2022]
Abstract
AIM To examine the generalizability of results from glucagon-like peptide-1 receptor agonist (GLP-1 RA) cardiovascular outcome trials (CVOTs) in the US type 2 diabetes (T2D) population. MATERIALS AND METHODS Patients enrolled or eligible for inclusion in four CVOTs (EXSCEL, LEADER, REWIND, and SUSTAIN-6) were examined in reference to a retrospective clinical database weighted to match the age and sex distribution of the US adult T2D population. We descriptively compared key baseline characteristics of the populations enrolled in each trial to those of the reference population and estimated the proportions of individuals in the reference population represented by those in the trials for each characteristic. We also estimated the proportions of individuals in the reference population that might have been enrolled in each trial based upon meeting the trial inclusion and exclusion (I/E) criteria. RESULTS No trial's enrolled population perfectly matched the reference population in key characteristics. The EXSCEL population most closely matched in mean age (62.7 vs. 60.5 years) and percentage with estimated glomerular filtration rate <60 (18.6 vs. 17.3%), while REWIND most closely matched in HbA1c, sex distribution, and proportion with a prior myocardial infarction. Based on I/E criteria, 42.6% of the reference population were eligible for enrolment in REWIND, versus 15.9% in EXSCEL, 13.0% in SUSTAIN-6, and 12.9% in LEADER. CONCLUSIONS Although none of the trials are fully representative of the general population, among the four trials examined, results from baseline REWIND were found to be more generalizable to the US adult T2D population than those of other GLP-1 RA CVOTs.
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Affiliation(s)
| | - Matthew C. Riddle
- Division of Endocrinology, Diabetes & Clinical NutritionOregon Health & Science UniversityPortlandOregon
| | - Hertzel C. Gerstein
- McMaster University and Hamilton Health Sciences CenterPopulation Health Research InstituteHamiltonOntarioCanada
| | - Reema Mody
- Eli Lilly and CompanyIndianapolisIndiana
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27
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Bain SC, Mosenzon O, Arechavaleta R, Bogdański P, Comlekci A, Consoli A, Deerochanawong C, Dungan K, Faingold MC, Farkouh ME, Franco DR, Gram J, Guja C, Joshi P, Malek R, Merino‐Torres JF, Nauck MA, Pedersen SD, Sheu WH‐H, Silver RJ, Tack CJ, Tandon N, Jeppesen OK, Strange M, Thomsen M, Husain M. Cardiovascular safety of oral semaglutide in patients with type 2 diabetes: Rationale, design and patient baseline characteristics for the PIONEER 6 trial. Diabetes Obes Metab 2019; 21:499-508. [PMID: 30284349 PMCID: PMC6587508 DOI: 10.1111/dom.13553] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/18/2018] [Accepted: 10/01/2018] [Indexed: 12/25/2022]
Abstract
AIMS To assess the cardiovascular (CV) safety of oral semaglutide, the first tablet formulation of a glucagon-like peptide-1 receptor agonist. MATERIALS AND METHODS PIONEER 6 is a multinational, randomized, placebo-controlled, double-blind trial in patients with type 2 diabetes at high risk of CV events (defined as being aged ≥50 years and having established CV disease [CVD] or moderate [stage 3] chronic kidney disease [CKD], or being aged ≥60 years with ≥1 other CV risk factor). Patients were randomized to once-daily oral semaglutide (up to 14 mg) or placebo added to standard of care. The primary composite endpoint is time to first occurrence of CV death or non-fatal myocardial infarction or non-fatal stroke. The primary hypothesis was to exclude an excess in CV risk with oral semaglutide by assessing non-inferiority versus placebo for the primary endpoint (non-inferiority margin of 1.8 for the upper boundary of the 95% confidence interval of the hazard ratio). PIONEER 6 is event-driven, with follow-up continuing until accrual of at least 122 primary outcome events. There is no pre-defined minimal duration. RESULTS Overall, 3183 patients have been enrolled (mean age 66.1 years, 31.6% females) in 214 sites across 21 countries. At baseline, the mean duration of diabetes was 14.9 years, mean glycated haemoglobin concentration was 66 mmol/mol (8.2%), and 84.6% of patients had established CVD/moderate CKD. CONCLUSIONS PIONEER 6 will provide evidence regarding the CV safety of oral semaglutide in patients with type 2 diabetes and high CV risk.
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Affiliation(s)
- Stephen C. Bain
- Diabetes Research Unit CymruSwansea University Medical SchoolSwanseaUK
| | - Ofri Mosenzon
- Diabetes Unit, Division of Internal MedicineHadassah Hebrew University HospitalJerusalemIsrael
| | | | - Pawel Bogdański
- Department of Education and Obesity Treatment and Metabolic DisordersPoznan University of Medical SciencesPoznanPoland
| | - Abdurrahman Comlekci
- Department of EndocrinologyDokuz Eylul University Faculty of Medicine, BalcovaIzmirTurkey
| | - Agostino Consoli
- Department of Medicine and Aging, and Center of Aging Science and Translational Medicine (CESI‐Met)"G. d'Annunzio" University of Chieti‐PescaraChietiItaly
| | | | - Kathleen Dungan
- Division of Endocrinology, Diabetes and MetabolismOhio State UniversityColumbusOhio
| | - Maria C. Faingold
- Department of Endocrinology and MetabolismDr Cesar Milstein HospitalBuenos AiresArgentina
| | - Michael E. Farkouh
- Peter Munk Cardiac Centre, University Health Network, Department of Medicine and the Heart and Stroke Richard Lewar CentreUniversity of TorontoTorontoOntarioCanada
| | | | - Jeppe Gram
- Department of EndocrinologyHospital of Southwest DenmarkEsbjergDenmark
| | - Cristian Guja
- Department of Diabetes, Nutrition and Metabolic DiseasesUniversity of Medicine and Pharmacy 'Carol Davila'BucharestRomania
| | - Pankaj Joshi
- Diabetes Care and Clinical Trials CentrePretoriaSouth Africa
| | - Rachid Malek
- Department of Internal MedicineCHU SétifSétifAlgeria
| | | | - Michael A. Nauck
- Diabetes Center Bochum‐Hattingen, Medical Department ISt Josef‐Hospital, Ruhr‐University BochumBochumGermany
| | - Sue D. Pedersen
- C‐ENDO Diabetes and Endocrinology ClinicCalgaryAlberta, Canada
| | - Wayne H. ‐H. Sheu
- Division of Endocrinology and Metabolism, Department of Internal MedicineTaichung Veterans General HospitalTaichungTaiwan
- School of MedicineNational Yang‐Ming UniversityTaipeiTaiwan
- School of MedicineNational Defense Medical CentreTaipeiTaiwan
| | - Robert J. Silver
- Southern New Hampshire Diabetes and EndocrinologyNashuaNew Hampshire
| | - Cees J. Tack
- Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
| | - Nikhil Tandon
- Department of Endocrinology and MetabolismAll India Institute of Medical SciencesNew DelhiIndia
| | | | | | | | - Mansoor Husain
- Peter Munk Cardiac Centre, University Health Network, Department of Medicine and the Heart and Stroke Richard Lewar CentreUniversity of TorontoTorontoOntarioCanada
- Toronto General Hospital Research Institute, and the Ted Rogers Centre for Heart ResearchTorontoCanada
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28
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Wolsk E, Claggett B, Diaz R, Dickstein K, Gerstein HC, Køber L, Lawson FC, Lewis EF, Maggioni AP, McMurray JJV, Probstfield JL, Riddle MC, Solomon SD, Tardif JC, Pfeffer MA. Increases in Natriuretic Peptides Precede Heart Failure Hospitalization in Patients With a Recent Coronary Event and Type 2 Diabetes Mellitus. Circulation 2019; 136:1560-1562. [PMID: 29038210 DOI: 10.1161/circulationaha.117.029503] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Emil Wolsk
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
| | - Brian Claggett
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.).
| | - Rafael Diaz
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
| | - Kenneth Dickstein
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
| | - Hertzel C Gerstein
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
| | - Lars Køber
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
| | - Francesca C Lawson
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
| | - Eldrin F Lewis
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
| | - Aldo P Maggioni
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
| | - John J V McMurray
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
| | - Jeffrey L Probstfield
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
| | - Matthew C Riddle
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
| | - Scott D Solomon
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
| | - Jean-Claude Tardif
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
| | - Marc A Pfeffer
- From Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.W., B.C., E.F.L., S.D.S., M.A.P.); Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (E.W., L.K.); Estudios Clínicos Latinoamérica, Rosario, Argentina (R.D.); University of Bergen, Stavanger University Hospital, Norway (K.D.); Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada (H.C.G.); Sanofi US, Bridgewater, NJ (F.C.L.); Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy (A.P.M.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Division of Cardiology, University of Washington Medical Center, Seattle (J.L.P.); Division of Endocrinology, Oregon Health and Science University, Portland (M.C.R.); and Montreal Heart Institute, Université de Montréal, Quebec, Canada (J.-C.T.)
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Patti AM, Giglio RV, Papanas N, Rizzo M, Rizvi AA. Future perspectives of the pharmacological management of diabetic dyslipidemia. Expert Rev Clin Pharmacol 2019; 12:129-143. [PMID: 30644763 DOI: 10.1080/17512433.2019.1567328] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Diabetic dyslipidemia is frequent among patients with type 2 diabetes mellitus (T2DM) and is characterized by an increase in triglycerides (TGs), low-density lipoprotein cholesterol (LDL-C), and small-dense (atherogenic) particles, and by a decrease in low high-density lipoprotein cholesterol (HDL-C) and apolipoprotein (Apo) A1 that are strongly related to insulin resistance. The increased flux of free fatty acids from adipose tissue to the liver aggravates hepatic insulin resistance and promotes all of aspects of the dyslipidemic state. Areas covered: Statins are the first-line agents for treatment while other lipid-lowering drugs (ezetimibe, fibrate and proprotein convertase subtilisin/kexin type 9) or novel anti-diabetic agents (dipeptidyl peptidase-4 inhibitors (DPP-4is), glucagon like peptide-1 receptor agonist (GLP-1RA), sodium/glucose cotransporter 2 inhibitors (SGLT2is)) or nutraceuticals (berberine, omega 3 fatty acid, red yeast rice) can be used alone or in combination. Expert commentary: In patients with T2DM, lipid abnormalities should be identified and treated as part of the overall diabetic treatment, in order to prevent cardiovascular disease. The choice of drugs to be used is mainly based on the lipid profile and on the characteristic lipoprotein abnormalities; the use of new drugs for the treatment of hyperglycemia and lipids alteration in these patients can improve diabetic dyslipidemia.
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Affiliation(s)
- Angelo Maria Patti
- a Biomedical Department of Internal Medicine and Medical Specialties , University of Palermo , Palermo , Italy
| | - Rosaria Vincenza Giglio
- a Biomedical Department of Internal Medicine and Medical Specialties , University of Palermo , Palermo , Italy
| | - Nikolaos Papanas
- b Diabetes Centre, Second Department of Internal Medicine , Democritus University of Thrace, University Hospital of Alexandroupolis , Alexandroupolis , Greece
| | - Manfredi Rizzo
- a Biomedical Department of Internal Medicine and Medical Specialties , University of Palermo , Palermo , Italy.,c Division of Endocrinology , Diabetes and Metabolism University of South Carolina School of Medicine Columbia , South Carolina , SC , USA
| | - Ali A Rizvi
- c Division of Endocrinology , Diabetes and Metabolism University of South Carolina School of Medicine Columbia , South Carolina , SC , USA
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Muskiet MHA, Tonneijck L, Huang Y, Liu M, Saremi A, Heerspink HJL, van Raalte DH. Lixisenatide and renal outcomes in patients with type 2 diabetes and acute coronary syndrome: an exploratory analysis of the ELIXA randomised, placebo-controlled trial. Lancet Diabetes Endocrinol 2018; 6:859-869. [PMID: 30292589 DOI: 10.1016/s2213-8587(18)30268-7] [Citation(s) in RCA: 145] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 08/23/2018] [Accepted: 08/29/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND The results of the ELIXA trial demonstrated the cardiovascular safety of lixisenatide, a short-acting glucagon-like peptide-1 receptor agonist, in patients with type 2 diabetes and acute coronary syndrome. In this exploratory analysis of ELIXA, we investigate the effect of lixisenatide on renal outcomes. METHODS ELIXA was a randomised, double-blind, placebo-controlled trial, done at 828 sites in 49 countries. Patients with type 2 diabetes and a recent coronary artery event were randomly assigned (1:1) to a daily subcutaneous injection of lixisenatide (10-20 μg) or volume-matched placebo, in addition to usual care, until at least 844 patients had an adjudicated major adverse cardiovascular event included in the primary outcome. Patients, study staff, and individuals involved in analysis of trial data were masked to treatment assignment. The primary and secondary endpoints of this trial have been reported previously. Here, in an exploratory analysis of ELIXA, we investigated percentage change in urinary albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) according to prespecified albuminuria status at baseline (normoalbuminuria [UACR <30 mg/g]; microalbuminuria [≥30 to ≤300 mg/g]; and macroalbuminuria [>300 mg/g]) using a mixed-effect model with repeated measures. Time to new-onset macroalbuminuria and doubling of serum creatinine were also assessed with Cox proportional hazards models. The ELIXA trial is registered with ClinicalTrials.gov, number NCT01147250, and is completed. FINDINGS Of 6068 patients randomly allocated between July 9, 2010, and Aug 2, 2013, baseline UACR data were available for 5978 (99%). Median follow-up time was 108 weeks. 4441 (74%; 2191 assigned to placebo and 2250 assigned to lixisenatide) had normoalbuminuria, 1148 (19%; 596 assigned to placebo and 552 assigned to lixisenatide) had microalbuminuria, and 389 (7%; 207 assigned to placebo and 182 assigned to lixisenatide) had macroalbuminuria. After 108 weeks, the placebo-adjusted least-squares mean percentage change in UACR from baseline with lixisenatide was -1·69% (95% CI -11·69 to 8·30; p=0·7398) in patients with normoalbuminuria, -21·10% (-42·25 to 0·04; p=0·0502) in patients with microalbuminuria, and -39·18% (-68·53 to -9·84; p=0·0070) in patients with macroalbuminuria. Lixisenatide was associated with a reduced risk of new-onset macroalbuminuria compared with placebo when adjusted for baseline HbA1c (hazard ratio [HR] 0·808 [95% CI 0·660 to 0·991; p=0·0404]) or baseline and on-trial HbA1c (HR 0·815 [0·665 to 0·999; p=0·0491]); point estimates were similar when adjusted for other traditional renal risk factors. At week 108, the largest eGFR decline from baseline was observed in the macroalbuminuric group, but no significant differences were observed between the two treatment groups. No significant differences in eGFR decline were identified between treatment groups in any UACR subgroup. In the trial safety population, doubling of serum creatinine occurred in 35 (1%) of 3032 patients in the placebo group and 41 (1%) of 3031 patients in the lixisenatide group (HR 1·163, 95% CI 0·741-1·825; p=0·5127). As previously reported in the ELIXA trial, the proportion of patients with renal adverse events was low (48 [1·6%] of 3032 patients in the placebo group vs 48 [1·6%] of 3031 patients in the lixisenatide group) and did not significantly differ between treatment groups. INTERPRETATION Lixisenatide reduces progression of UACR in macroalbuminuric patients, and is associated with a lower risk of new-onset macroalbuminuria after adjustment for baseline and on-trial HbA1c and other traditional renal risk factors. FUNDING Sanofi.
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Affiliation(s)
- Marcel H A Muskiet
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, Netherlands.
| | - Lennart Tonneijck
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, Netherlands
| | | | | | | | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Daniël H van Raalte
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, Netherlands
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Harmony Outcomes: A randomized, double-blind, placebo-controlled trial of the effect of albiglutide on major cardiovascular events in patients with type 2 diabetes mellitus-Rationale, design, and baseline characteristics. Am Heart J 2018; 203:30-38. [PMID: 30015066 DOI: 10.1016/j.ahj.2018.03.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/23/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Albiglutide is a long-acting glucagon-like peptide-1 receptor agonist that improves glycemic control in patients with type 2 diabetes mellitus (T2DM). Harmony Outcomes is a randomized, double-blind, placebo-controlled trial of the effect of albiglutide on major adverse cardiovascular (CV) events in patients with T2DM and established CV disease. METHODS The trial was designed to recruit 9,400 patients aged ≥40 years with T2DM, prior atherosclerotic CV disease, and suboptimal glycemic control. Participants were assigned in a 1:1 ratio to albiglutide 30 mg (potentially increasing to 50 mg) or matching placebo administered once weekly by subcutaneous injection. The trial will continue until ≥611 confirmed primary outcome events (CV death, myocardial infarction, or stroke) occur over a median follow-up of at least 1.5 years. RESULTS A total of 9,463 patients were enrolled at 611 sites in 28 countries between July 2015 and December 2016. The mean age was 64.1 years; duration of T2DM, 13.8 years; and glycated hemoglobin, 8.7%. The percentage of patients with prior coronary artery disease was 70.5%; peripheral arterial disease, 25.0%; stroke, 17.7%; heart failure, 20.2%; and chronic kidney disease, 22.6%. CONCLUSIONS Harmony Outcomes will assess the CV safety of albiglutide in patients with T2DM and CV disease. Trials of other agents in the glucagon-like peptide-1 receptor agonist class have shown CV benefit for only some of these medications, possibly due to differences in trial design or instead due to differences in drug structure or metabolism. Harmony Outcomes will provide information critical to our understanding of this heterogenous class of glucose-lowering agents.
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Seguridad de los inhibidores de la dipeptidil peptidasa 4. Semergen 2018; 44 Suppl 1:10-17. [DOI: 10.1016/s1138-3593(18)30370-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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GLP-1 receptor agonists and reduction of cardiometabolic risk: Potential underlying mechanisms. Biochim Biophys Acta Mol Basis Dis 2018; 1864:2814-2821. [PMID: 29778663 DOI: 10.1016/j.bbadis.2018.05.012] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus (T2DM) is a metabolic condition with an elevated impact on cardiovascular (CV) risk. The innovative therapeutic approaches for T2DM - incretin-based therapies (IBTs), including glucagon-like peptide 1 (GLP-1) receptor agonists, have become popular and more widely used in recent years. The available scientific data from clinical studies and clinical practice highlights their beyond glucose-lowering effects, which is achieved without any increase in hypoglycaemia. The former effects include reduction in body weight, lipids, blood pressure, inflammatory markers, oxidative stress, endothelial dysfunction, and subclinical atherosclerosis, thus reducing and potentially preventing CV events. In fact, the introduction of IBTs is one of the key moments in the history of diabetes research and treatment. Such therapeutic strategies allow customization of antidiabetic treatment to each patient's need and therefore obtain better metabolic control with reduced CV risk. The aim of the present paper is to provide a comprehensive overview of the effects of GLP-1RA on various cardiometabolic markers and overall CV risk, with particular attention on recent CV outcome studies and potential mechanisms. In particular, the effects of liraglutide on formation and progression of atherosclerotic plaque and mechanisms explaining its cardioprotective effects are highlighted.
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Abstract
Albiglutide is a long acting GLP-1 receptor agonist (GLP-1 RA) administered by weekly injection and approved for use in type 2 diabetes. It has less gastrointestinal side effects than other GLP-1 RAs in current use but does not improve HbA1c or promote weight loss to the same extent as some competitor agents. Area covered: The current use of albiglutide is discussed. The review encompassed a search of PubMed and a thorough analysis of the European Union and US Food and Drug Administration approval documents. Expert opinion: Unlike competitor agents, the gastrointestinal side effects of albiglutide are not much greater than placebo. It has been studied and appears safe at all stages of renal failure. There exists concern about an imbalance of pancreatitis cases in the approval program as well as injection site reactions which led to discontinuance of therapy in up to 2% of participants. A large long-term study is now underway to determine if albiglutide, with its relatively favorable GI tolerance, has a place in the treatment of patients with increased risk of cardiovascular events. At present, albiglutide is a safe agent to introduce GLP-1 RA treatment into the regimen for type 2 diabetes patients and may be the GLP-1 agent of choice in patients with renal insufficiency.
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Affiliation(s)
- Marc S Rendell
- a The Association of Diabetes Investigators , Newport Coast , CA , USA
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Seferovic JP, Bentley-Lewis R, Claggett B, Diaz R, Gerstein HC, Køber LV, Lawson FC, Lewis EF, Maggioni AP, McMurray JJV, Probstfield JL, Riddle MC, Solomon SD, Tardif JC, Pfeffer MA. Retinopathy, Neuropathy, and Subsequent Cardiovascular Events in Patients with Type 2 Diabetes and Acute Coronary Syndrome in the ELIXA: The Importance of Disease Duration. J Diabetes Res 2018; 2018:1631263. [PMID: 30648112 PMCID: PMC6311850 DOI: 10.1155/2018/1631263] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 09/18/2018] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION We investigated the association of diabetic retinopathy and neuropathy with increased risk of recurrent cardiovascular (CV) events in 6068 patients with type 2 diabetes mellitus (T2DM) and recent acute coronary syndrome (ACS) enrolled in the Evaluation of Lixisenatide in Acute Coronary Syndrome (ELIXA). METHODS History of retinopathy and neuropathy as well as duration of T2DM were self-reported at screening. Proportional hazards regression models were used to assess relationships between retinopathy, neuropathy, and recurrent CV events. RESULTS At screening, retinopathy and neuropathy were reported in 10.7% and 17.5% of patients, respectively, while 5.7% reported both. When adjusted for randomized treatment only, both retinopathy and neuropathy were associated with a primary composite outcome (CV death, nonfatal MI, stroke, or hospitalization for unstable angina) (retinopathy: HR 1.44, 95% CI 1.19-1.75; neuropathy: HR 1.33, 95% CI 1.12-1.57), CV composite (CV death, nonfatal MI, stroke, hospitalization for heart failure (HF)) (retinopathy: HR 1.57, 95% CI 1.31-1.88; neuropathy: HR 1.38, 95% CI 1.19-1.62), myocardial infarction (retinopathy: HR 1.38, 95% CI 1.08-1.76; neuropathy: HR 1.26, 95% CI 1.02-1.54), HF hospitalization (retinopathy: HR 2.03, 95% CI 1.48-2.78; neuropathy: HR 1.71, 95% CI 1.30-2.27), and all-cause mortality (retinopathy: HR 1.65, 95% CI 1.28-2.12; neuropathy: HR 1.43, 95% CI 1.14-1.78). When included in the same model, and adjusted for T2DM duration, there were no independent associations of either with CV outcomes, while T2DM duration remained strongly associated with all outcomes. Addition of demographic characteristics and CV risk factors did not further alter these relationships. CONCLUSIONS In patients with T2DM and recent ACS, a history of retinopathy and/or neuropathy and longer T2DM duration could be considered clinical markers for high risk of recurrent CV events. This trial is registered with the ELIXA (Evaluation of Lixisenatide in Acute Coronary Syndrome), ClinicalTrials.gov registration number NCT01147250.
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Affiliation(s)
- Jelena P. Seferovic
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Rosario, Argentina
| | | | - Lars V. Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Eldrin F. Lewis
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aldo P. Maggioni
- Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy
| | - John J. V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | | | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Marc A. Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Owens DR, Monnier L, Hanefeld M. A review of glucagon-like peptide-1 receptor agonists and their effects on lowering postprandial plasma glucose and cardiovascular outcomes in the treatment of type 2 diabetes mellitus. Diabetes Obes Metab 2017; 19:1645-1654. [PMID: 28474401 PMCID: PMC5697665 DOI: 10.1111/dom.12998] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 04/28/2017] [Accepted: 04/28/2017] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus (T2DM) is an independent risk factor for cardiovascular (CV) comorbidities, with CV disease being the most common cause of death in adults with T2DM. Although glucocentric therapies may improve glycaemic control (as determined by glycated haemoglobin levels), evidence suggests that this approach alone has limited beneficial effects on CV outcomes relative to improvements in lipid and blood pressure control. This may be explained in part by the fact that current antidiabetic treatment regimens primarily address overall glycaemia and/or fasting plasma glucose, but not the postprandial plasma glucose (PPG) excursions that have a fundamental causative role in increasing CV risk. This literature review evaluates the relationship between PPG and the risk of CV disease, discusses the treatment of T2DM with glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and examines the associated CV outcomes. The literature analysis suggests that exaggerated PPG excursions are a risk factor for CV disease because of their adverse pathophysiologic effects on the vasculature, resulting in increased all-cause and CV-related mortality. Although GLP-1 RAs are well established in the current T2DM treatment paradigm, a subgroup of these compounds has a particularly pronounced, persistent and short-lived effect on gastric emptying and, hence, lower PPG substantially. However, current long-term data on CV outcomes with GLP-1 RAs are contradictory, with both beneficial and adverse effects having been reported. This review explores the opportunity to direct treatment towards controlling PPG excursions, thereby improving not only overall glycaemic control but also CV outcomes.
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Affiliation(s)
- David R. Owens
- Diabetes Research Group, Institute of Life Sciences College of MedicineSwansea UniversitySwanseaUK
| | - Louis Monnier
- Laboratory of Human Nutrition and Atherosclerosis, Institute of Clinical ResearchUniversity of MontpellierMontpellierFrance
| | - Markolf Hanefeld
- Study Centre “Professor Hanefeld”GWT‐Technical University DresdenDresdenGermany
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Wewer Albrechtsen NJ, Albrechtsen R, Bremholm L, Svendsen B, Kuhre RE, Poulsen SS, Christiansen CB, Jensen EP, Janus C, Hilsted L, Deacon CF, Hartmann B, Holst JJ. Glucagon-like Peptide 1 Receptor Signaling in Acinar Cells Causes Growth-Dependent Release of Pancreatic Enzymes. Cell Rep 2017; 17:2845-2856. [PMID: 27974199 DOI: 10.1016/j.celrep.2016.11.051] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 10/31/2016] [Accepted: 11/15/2016] [Indexed: 12/19/2022] Open
Abstract
Incretin-based therapies are widely used for type 2 diabetes and now also for obesity, but they are associated with elevated plasma levels of pancreatic enzymes and perhaps a modestly increased risk of acute pancreatitis. However, little is known about the effects of the incretin hormone glucagon-like peptide 1 (GLP-1) on the exocrine pancreas. Here, we identify GLP-1 receptors on pancreatic acini and analyze the impact of receptor activation in humans, rodents, isolated acini, and cell lines from the exocrine pancreas. GLP-1 did not directly stimulate amylase or lipase release. However, we saw that GLP-1 induces phosphorylation of the epidermal growth factor receptor and activation of Foxo1, resulting in cell growth with concomitant enzyme release. Our work uncovers GLP-1-induced signaling pathways in the exocrine pancreas and suggests that increases in amylase and lipase levels in subjects treated with GLP-1 receptor agonists reflect adaptive growth rather than early-stage pancreatitis.
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Affiliation(s)
- Nicolai J Wewer Albrechtsen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark; NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Reidar Albrechtsen
- Department of Biomedical Sciences and Biotech Research and Innovation Centre (BRIC), University of Copenhagen, 2200 Copenhagen, Denmark
| | - Lasse Bremholm
- Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
| | - Berit Svendsen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark; NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Rune E Kuhre
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark; NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Steen S Poulsen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark; NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Charlotte B Christiansen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark; NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Elisa P Jensen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark; NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Charlotte Janus
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark; NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Linda Hilsted
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Carolyn F Deacon
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark; NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Bolette Hartmann
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark; NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark; NNF Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark.
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Herman ME, O'Keefe JH, Bell DSH, Schwartz SS. Insulin Therapy Increases Cardiovascular Risk in Type 2 Diabetes. Prog Cardiovasc Dis 2017; 60:422-434. [PMID: 28958751 DOI: 10.1016/j.pcad.2017.09.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 09/20/2017] [Indexed: 12/11/2022]
Abstract
Insulin therapy increased cardiovascular (CV) risk and mortality among type 2 diabetes (T2D) patients in several recently reported clinical outcomes trials. To assess whether this association is causative or coincidental, PubMed searches were used to query the effects of insulin therapy for T2D on CV health and longevity from large-scale outcomes trials, meta-analyses, and patient registry studies, as well as basic research on insulin's direct and pleiotropic actions. Although several old studies provided conflicting results, the majority of large observational studies show strong dose-dependent associations for injected insulin with increased CV risk and worsened mortality. Insulin clearly causes weight gain, recurrent hypoglycemia, and, other potential adverse effects, including iatrogenic hyperinsulinemia. This over-insulinization with use of injected insulin predisposes to inflammation, atherosclerosis, hypertension, dyslipidemia, heart failure (HF), and arrhythmias. These associations support the findings of large-scale evaluations that strongly suggest that insulin therapy has a poorer short- and long-term safety profile than that found to many other anti-T2D therapies. The potential adverse effects of insulin therapy should be weighed against proven CV benefits noted for select other therapies for T2D as reported in recent large randomized controlled trials.
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Affiliation(s)
- Mary E Herman
- Montclair State University, New Jersey, United States; Social Alchemy Ltd. Building Global Research Competency, United States
| | - James H O'Keefe
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, United States; Saint Luke's Mid America Heart Institute, United States.
| | | | - Stanley S Schwartz
- Main Line Health System, Wynnewood, PA, United States; University of Pennsylvania, Philadelphia, PA, United States
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Nauck MA, Meier JJ, Cavender MA, Abd El Aziz M, Drucker DJ. Cardiovascular Actions and Clinical Outcomes With Glucagon-Like Peptide-1 Receptor Agonists and Dipeptidyl Peptidase-4 Inhibitors. Circulation 2017; 136:849-870. [PMID: 28847797 DOI: 10.1161/circulationaha.117.028136] [Citation(s) in RCA: 351] [Impact Index Per Article: 50.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Potentiation of glucagon-like peptide-1 (GLP-1) action through selective GLP-1 receptor (GLP-1R) agonism or by prevention of enzymatic degradation by inhibition of dipeptidyl peptidase-4 (DPP-4) promotes glycemic reduction for the treatment of type 2 diabetes mellitus by glucose-dependent control of insulin and glucagon secretion. GLP-1R agonists also decelerate gastric emptying, reduce body weight by reduction of food intake and lower circulating lipoproteins, inflammation, and systolic blood pressure. Preclinical studies demonstrate that both GLP-1R agonists and DPP-4 inhibitors exhibit cardioprotective actions in animal models of myocardial ischemia and ventricular dysfunction through incompletely characterized mechanisms. The results of cardiovascular outcome trials in human subjects with type 2 diabetes mellitus and increased cardiovascular risk have demonstrated a cardiovascular benefit (significant reduction in time to first major adverse cardiovascular event) with the GLP-1R agonists liraglutide (LEADER trial [Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Ourcome Results], -13%) and semaglutide (SUSTAIN-6 trial [Trial to Evaluate Cardiovascular and Other Long-term Outcomes with Semaglutide], -24%). In contrast, cardiovascular outcome trials examining the safety of the shorter-acting GLP-1R agonist lixisenatide (ELIXA trial [Evaluation of Lixisenatide in Acute Coronary Syndrom]) and the DPP-4 inhibitors saxagliptin (SAVOR-TIMI 53 trial [Saxagliptin Assessment of Vascular Outcomes Recorded in Patients With Diabetes Mellitus-Thrombolysis in Myocardial Infarction 53]), alogliptin (EXAMINE trial [Examination of Cardiovascular Outcomes With Alogliptin Versus Standard of Care in Patients With Type 2 Diabetes Mellitus and Acute Coronary Syndrome]), and sitagliptin (TECOS [Trial Evaluating Cardiovascular Outcomes With Sitagliptin]) found that these agents neither increased nor decreased cardiovascular events. Here we review the cardiovascular actions of GLP-1R agonists and DPP-4 inhibitors, with a focus on the translation of mechanisms derived from preclinical studies to complementary findings in clinical studies. We highlight areas of uncertainty requiring more careful scrutiny in ongoing basic science and clinical studies. As newer more potent GLP-1R agonists and coagonists are being developed for the treatment of type 2 diabetes mellitus, obesity, and nonalcoholic steatohepatitis, the delineation of the potential mechanisms that underlie the cardiovascular benefit and safety of these agents have immediate relevance for the prevention and treatment of cardiovascular disease.
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Affiliation(s)
- Michael A Nauck
- From Diabetes Center Bochum-Hattingen, St Josef-Hospital, Ruhr-University Bochum, Germany (M.A.N., J.J.M., M.A.E.A.); Department of Medicine, University of North Carolina, Chapel Hill (M.A.C.); and Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mt Sinai Hospital, University of Toronto, Ontario, Canada (D.J.D.).
| | - Juris J Meier
- From Diabetes Center Bochum-Hattingen, St Josef-Hospital, Ruhr-University Bochum, Germany (M.A.N., J.J.M., M.A.E.A.); Department of Medicine, University of North Carolina, Chapel Hill (M.A.C.); and Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mt Sinai Hospital, University of Toronto, Ontario, Canada (D.J.D.)
| | - Matthew A Cavender
- From Diabetes Center Bochum-Hattingen, St Josef-Hospital, Ruhr-University Bochum, Germany (M.A.N., J.J.M., M.A.E.A.); Department of Medicine, University of North Carolina, Chapel Hill (M.A.C.); and Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mt Sinai Hospital, University of Toronto, Ontario, Canada (D.J.D.)
| | - Mirna Abd El Aziz
- From Diabetes Center Bochum-Hattingen, St Josef-Hospital, Ruhr-University Bochum, Germany (M.A.N., J.J.M., M.A.E.A.); Department of Medicine, University of North Carolina, Chapel Hill (M.A.C.); and Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mt Sinai Hospital, University of Toronto, Ontario, Canada (D.J.D.)
| | - Daniel J Drucker
- From Diabetes Center Bochum-Hattingen, St Josef-Hospital, Ruhr-University Bochum, Germany (M.A.N., J.J.M., M.A.E.A.); Department of Medicine, University of North Carolina, Chapel Hill (M.A.C.); and Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mt Sinai Hospital, University of Toronto, Ontario, Canada (D.J.D.)
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Abstract
INTRODUCTION Albiglutide is a marketed long acting GLP-1 receptor agonist (GLP-1 RA) administered by weekly injection. It has significantly less gastrointestinal side effects than other GLP-1 RAs in current use but does not improve HbA1c or promote weight loss to the same extent as competitor agents such as liraglutide. Area Covered: The safety of albiglutide is discussed. The review encompassed a search of PubMed and a thorough analysis of the European Union and US Food and Drug Administration approval documents. Expert Opinion: Unlike competitor agents, the gastrointestinal side effects of albiglutide are not much greater than placebo. It has been studied and appears safe at all stages of renal failure. There exists concern about an imbalance of pancreatitis cases in the approval program as well as injection site reactions which led to discontinuance of therapy in up to 2% of participants. A large long term study now underway will determine if albiglutide, with its relatively favorable GI tolerance, has a place in the treatment of patients with increased risk of cardiovascular events.
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Affiliation(s)
- Marc S Rendell
- a The Association of Diabetes Investigators , Newport Coast , CA , USA
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Gray A, McQuillan C, Menown IBA. Advances in Clinical Cardiology 2016: A Summary of the Key Clinical Trials. Adv Ther 2017; 34:1503-1527. [PMID: 28537000 PMCID: PMC5504210 DOI: 10.1007/s12325-017-0560-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The findings of many new cardiology clinical trials over the last year have been published or presented at major international meetings. This paper aims to describe and place in context a summary of the key clinical trials in cardiology presented between January and December 2016. METHODS The authors reviewed clinical trials presented at major cardiology conferences during 2016 including the American College of Cardiology (ACC), European Association for Percutaneous Cardiovascular Interventions (EuroPCR), European Society of Cardiology (ESC), European Association for the Study of Diabetes (EASD), Transcatheter Cardiovascular Therapeutics (TCT), and the American Heart Association (AHA). Selection criteria were trials with a broad relevance to the cardiology community and those with potential to change current practice. RESULTS A total of 57 key cardiology clinical trials were identified for inclusion. Here we describe and place in clinical context the key findings of new data relating to interventional and structural cardiology including delayed stenting following primary angioplasty, contrast-induced nephropathy, management of jailed wires, optimal duration of dual antiplatelet therapy (DAPT), stenting vs bypass for left main disease, new generation stents (BioFreedom, Orsiro, Absorb), transcatheter aortic valve implantation (Edwards Sapien XT, transcatheter embolic protection), and closure devices (Watchman, Amplatzer). New preventative cardiology data include trials of bariatric surgery, empagliflozin, liraglutide, semaglutide, PCSK9 inhibitors (evolocumab and alirocumab), and inclisiran. Antiplatelet therapy trials include platelet function monitoring and ticagrelor vs clopidogrel for peripheral vascular disease. New data are also presented in fields of heart failure (sacubitril/valsartan, aliskiren, spironolactone), atrial fibrillation (rivaroxaban in patients undergoing coronary intervention, edoxaban in DC cardioversion), cardiac devices (implantable cardioverter defibrillator in non-ischemic cardiomyopathy), and electrophysiology (cryoballoon vs radiofrequency ablation). CONCLUSION This paper presents a summary of key clinical cardiology trials during the past year and should be of practical value to both clinicians and cardiology researchers.
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Affiliation(s)
- Alastair Gray
- Craigavon Cardiac Centre, Southern Trust, Craigavon, Northern Ireland, UK
| | - Conor McQuillan
- Craigavon Cardiac Centre, Southern Trust, Craigavon, Northern Ireland, UK
| | - Ian B A Menown
- Craigavon Cardiac Centre, Southern Trust, Craigavon, Northern Ireland, UK.
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Wolsk E, Claggett B, Pfeffer MA, Diaz R, Dickstein K, Gerstein HC, Lawson FC, Lewis EF, Maggioni AP, McMurray JJV, Probstfield JL, Riddle MC, Solomon SD, Tardif JC, Køber L. Role of B-Type Natriuretic Peptide and N-Terminal Prohormone BNP as Predictors of Cardiovascular Morbidity and Mortality in Patients With a Recent Coronary Event and Type 2 Diabetes Mellitus. J Am Heart Assoc 2017; 6:JAHA.116.004743. [PMID: 28554908 PMCID: PMC5669146 DOI: 10.1161/jaha.116.004743] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Natriuretic peptides are recognized as important predictors of cardiovascular events in patients with heart failure, but less is known about their prognostic importance in patients with acute coronary syndrome. We sought to determine whether B-type natriuretic peptide (BNP) and N-terminal prohormone B-type natriuretic peptide (NT-proBNP) could enhance risk prediction of a broad range of cardiovascular outcomes in patients with acute coronary syndrome and type 2 diabetes mellitus. METHODS AND RESULTS Patients with a recent acute coronary syndrome and type 2 diabetes mellitus were prospectively enrolled in the ELIXA trial (n=5525, follow-up time 26 months). Best risk models were constructed from relevant baseline variables with and without BNP/NT-proBNP. C statistics, Net Reclassification Index, and Integrated Discrimination Index were analyzed to estimate the value of adding BNP or NT-proBNP to best risk models. Overall, BNP and NT-proBNP were the most important predictors of all outcomes examined, irrespective of history of heart failure or any prior cardiovascular disease. BNP significantly improved C statistics when added to risk models for each outcome examined, the strongest increments being in death (0.77-0.82, P<0.001), cardiovascular death (0.77-0.83, P<0.001), and heart failure (0.84-0.87, P<0.001). BNP or NT-proBNP alone predicted death as well as all other variables combined (0.77 versus 0.77). CONCLUSIONS In patients with a recent acute coronary syndrome and type 2 diabetes mellitus, BNP and NT-proBNP were powerful predictors of cardiovascular outcomes beyond heart failure and death, ie, were also predictive of MI and stroke. Natriuretic peptides added as much predictive information about death as all other conventional variables combined. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01147250.
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Affiliation(s)
- Emil Wolsk
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Brian Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Rosario, Argentina
| | - Kenneth Dickstein
- University of Bergen Stavanger University Hospital, Stavanger, Norway
| | - Hertzel C Gerstein
- Division of Endocrinology & Metabolism, McMaster University, Hamilton, Ontario, Canada
| | | | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Aldo P Maggioni
- Research Center of the Italian Association of Hospital Cardiologists, Florence, Italy
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | | | - Matthew C Riddle
- Division of Endocrinology, Oregon Health and Science University, Portland, OR
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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Mentz RJ, Bethel MA, Gustavson S, Thompson VP, Pagidipati NJ, Buse JB, Chan JC, Iqbal N, Maggioni AP, Marso SP, Ohman P, Poulter N, Ramachandran A, Zinman B, Hernandez AF, Holman RR. Baseline characteristics of patients enrolled in the Exenatide Study of Cardiovascular Event Lowering (EXSCEL). Am Heart J 2017; 187:1-9. [PMID: 28454792 PMCID: PMC9849915 DOI: 10.1016/j.ahj.2017.02.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 02/08/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND EXSCEL is a randomized, double-blind, placebo-controlled trial examining the effect of exenatide once-weekly (EQW) versus placebo on time to the primary composite outcome (cardiovascular death, nonfatal myocardial infarction or nonfatal stroke) in patients with type 2 diabetes mellitus (DM) and a wide range of cardiovascular (CV) risk. METHODS Patients were enrolled at 688 sites in 35 countries. We describe their baseline characteristics according to prior CV event status and compare patients with those enrolled in prior glucagon-like peptide-1 receptor agonist (GLP-1RA) outcomes trials. RESULTS Of a total of 14,752 participants randomized between June 2010 and September 2015, 6,788 (46.0%) patients were enrolled in Europe; 3,708 (25.1%), North America; 2,727 (18.5%), Latin America; and 1,529 (10.4%), Asia Pacific. Overall, 73% had at least one prior CV event (70% coronary artery disease, 24% peripheral arterial disease, 22% cerebrovascular disease). The median (IQR) age was 63 years (56, 69), 38% were female, median baseline HbA1c was 8.0% (7.3, 8.9) and 16% had a prior history of heart failure. Those without a prior CV event were younger with a shorter duration of diabetes and better renal function than those with at least one prior CV event. Compared with prior GLP-1RA trials, EXSCEL has a larger percentage of patients without a prior CV event and a notable percentage who were taking a dipeptidyl peptidase-4 inhibitor at baseline (15%). CONCLUSIONS EXSCEL is one of the largest global GLP-1RA trials, evaluating the safety and efficacy of EQW with a broad patient population that may extend generalizability compared to prior GLP-1RA trials (ClinicalTrials.gov number, NCT01144338).
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Affiliation(s)
| | | | | | | | | | - John B Buse
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Juliana C Chan
- The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - Nayyar Iqbal
- AstraZeneca Research and Development, Gaithersburg, MD
| | | | - Steve P Marso
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Peter Ohman
- AstraZeneca Research and Development, Gaithersburg, MD
| | - Neil Poulter
- International Centre for Circulatory Health, NHLI, Imperial College London, London, UK
| | - Ambady Ramachandran
- India Diabetes Research Foundation and Dr. A. Ramachandran's Diabetes Hospitals, Chennai, India
| | - Bernard Zinman
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | | | - Rury R Holman
- Diabetes Trials Unit, University of Oxford, Oxford, UK
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Rendell M. United States experience of insulin degludec alone or in combination for type 1 and type 2 diabetes. Drug Des Devel Ther 2017; 11:1209-1220. [PMID: 28458515 PMCID: PMC5402881 DOI: 10.2147/dddt.s132581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Insulin degludec has been the product of a sophisticated and systematic biochemical engineering program which began with the release of insulin detemir. The goal was to produce a long-lasting basal insulin with low individual variability. Certainly, this goal has been achieved. Degludec has a duration of action approaching twice that of glargine. Another advantage of degludec is in its lack of unpredictable copolymerization of added aspart. In several studies, degludec has shown lower rates of nocturnal hypoglycemia than glargine. Degludec can be administered flexibly with a very flat insulin concentration curve at any time of day. Initial US Food and Drug Administration concerns about a possible increase in cardiac events in degludec-treated patients have been allayed by the results of a study targeting individuals with high cardiac risk. Degludec is now marketed in the US competing with glargine. Despite the long duration of action of degludec, attempted administration three times weekly resulted in less effective lowering of glycated hemoglobin and an increased incidence of hypoglycemia compared to daily glargine. Conversely the coformulation of degludec and liraglutide has proven very successful in reducing glycated hemoglobin levels with less hypoglycemia and less weight gain than with degludec alone and with less gastrointestinal symptoms than with liraglutide alone. A large study comparing glargine insulin and degludec in patients with increased cardiac risk is now ongoing. This study may or may not prove superiority of one or the other insulin, but, with the coming of biosimilar glargine insulin, cost factors may be dominant in determining which basal insulin is to be used. Nonetheless, the coformulation with liraglutide will likely insure the future of degludec insulin in the treatment of type 2 diabetes.
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Affiliation(s)
- Marc Rendell
- The Rose Salter Medical Research Foundation
- The Association of Diabetes Investigators, Newport Coast, CA, USA
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Levin PA, Nguyen H, Wittbrodt ET, Kim SC. Glucagon-like peptide-1 receptor agonists: a systematic review of comparative effectiveness research. Diabetes Metab Syndr Obes 2017; 10:123-139. [PMID: 28435305 PMCID: PMC5389657 DOI: 10.2147/dmso.s130834] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Glucagon-like peptide-1 receptor agonists (GLP-1RAs) act by increasing insulin secretion, decreasing glucagon secretion, slowing gastric emptying, and increasing satiety. OBJECTIVE Published evidence directly comparing GLP-1RAs with other approved treatments for type 2 diabetes (T2D) was systematically reviewed. METHODS A literature search was performed using MEDLINE and Embase databases to identify papers comparing GLP-1RAs with other classes of glucose-lowering therapy in patients with T2D. RESULTS Of the 1303 papers identified, 57 met the prespecified criteria for a high-quality clinical trial or retrospective study. The efficacy and tolerability of approved GLP-1RAs (exenatide twice daily or once weekly, dulaglutide, liraglutide, lixisenatide, and albiglutide) were compared with insulin products (23 prospective studies + seven retrospective studies), dipeptidyl peptidase-4 inhibitors (11 prospective studies + three retrospective studies), sulfonylureas (nine prospective studies + one retrospective study), thiazolidinediones (five prospective studies), and metformin (two prospective studies). GLP-1RAs are effective as a second-line therapy in improving glycemic parameters in patients with T2D. Reductions in glycated hemoglobin from baseline with GLP-1RAs tended to be greater or similar compared with insulin therapy. GLP-1RAs were consistently more effective in reducing body weight than most oral glucose-lowering drugs and insulin and were associated with lower hypoglycemia risk versus insulin or sulfonylureas. GLP-1RAs improved cardiovascular risk factors, and preliminary data suggest they improve cardiovascular outcomes in patients with T2D compared with oral glucose-lowering drugs. However, results from ongoing studies are awaited to confirm these early findings. CONCLUSION This systematic review found that GLP-1RAs are an effective class of glucose-lowering drugs for T2D.
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Affiliation(s)
| | - Hiep Nguyen
- Health Economics and Outcomes Research, AstraZeneca, Wilmington, DE
| | - Eric T Wittbrodt
- Health Economics and Outcomes Research, AstraZeneca, Wilmington, DE
| | - Seoyoung C Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
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Hemodynamic effects by glucagon-like peptide-1 receptor analogues: what should be measured? J Hypertens 2017; 35:953-954. [PMID: 28353547 DOI: 10.1097/hjh.0000000000001315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Secrest MH, Udell JA, Filion KB. The cardiovascular safety trials of DPP-4 inhibitors, GLP-1 agonists, and SGLT2 inhibitors. Trends Cardiovasc Med 2017; 27:194-202. [PMID: 28291655 DOI: 10.1016/j.tcm.2017.01.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/26/2017] [Accepted: 01/27/2017] [Indexed: 01/22/2023]
Abstract
In this paper, we review the results of large, double-blind, placebo-controlled randomized trials mandated by the US Food and Drug Administration to examine the cardiovascular safety of newly-approved antihyperglycemic agents in patients with type 2 diabetes. The cardiovascular effects of dipeptidyl peptidase-4 (DPP-4) inhibitors remain controversial: while these drugs did not reduce or increase the risk of primary, pre-specified composite cardiovascular outcomes, one DPP-4 inhibitor (saxagliptin) increased the risk of hospitalization for heart failure in the overall population; another (alogliptin) demonstrated inconsistent effects on heart failure hospitalization across subgroups of patients, and a third (sitagliptin) demonstrated no effect on heart failure. Evidence for cardiovascular benefits of glucagon-like peptide-1 (GLP-1) agonists has been similarly heterogeneous, with liraglutide and semaglutide reducing the risk of composite cardiovascular outcomes, but lixisenatide having no reduction or increase in cardiovascular risk. The effect of GLP-1 agonists on retinopathy remains a potential concern. In the only completed trial to date to assess a sodium-glucose cotransporter-2 (SGLT2) inhibitor, empagliflozin reduced the risk of composite cardiovascular endpoints, predominantly through its impact on cardiovascular mortality and heart failure hospitalization.
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Affiliation(s)
- Matthew H Secrest
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Jacob A Udell
- Women's College Research Institute, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kristian B Filion
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Division of Clinical Epidemiology, Department of Medicine, McGill University, Montreal, Quebec, Canada.
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Abstract
Incretin-based therapies are important addition to our armamentarium for the treatment of type 2 diabetes (T2DM). There are six Glucagon-like peptide-1 receptor agonists (GLP-1RAs) which have received regulatory approval for clinical use. The short-acting GLP-1RAs include exenatide twice daily, liraglutide once daily, and lixisenatide once daily. The approved long-acting GLP-1RAs are administered weekly and are exenatide, albiglutide, and dulaglutide. Although all of these therapies lower hemoglobin A1C (HbA1C), there also are unique features of GLP-1RAs that have been made manifest from clinical trial data with regard to weight-loss efficacy, fasting and post-prandial glucose control, cardiovascular safety and protection, and gastrointestinal and injection adverse effects. It is imperative to consider these features when tailoring the choice of a GLP-1RA to patient specific characteristics.
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Affiliation(s)
- Susan L Samson
- Department of Medicine, Baylor College of Medicine, One Baylor Plaza, ABBR R615, Houston, TX, 77030, USA.
| | - Alan J Garber
- Departments of Medicine, Molecular and Cellular Biology, Biochemistry and Molecular Biology, Baylor College of Medicine, One Baylor Plaza, BCM 620, Houston, TX, 77030, USA
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50
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Pujadas G, Drucker DJ. Vascular Biology of Glucagon Receptor Superfamily Peptides: Mechanistic and Clinical Relevance. Endocr Rev 2016; 37:554-583. [PMID: 27732058 DOI: 10.1210/er.2016-1078] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Regulatory peptides produced in islet and gut endocrine cells, including glucagon, glucagon-like peptide-1 (GLP-1), GLP-2, and glucose-dependent insulinotropic polypeptide, exert actions with considerable metabolic importance and translational relevance. Although the clinical development of GLP-1 receptor agonists and dipeptidyl peptidase-4 inhibitors has fostered research into how these hormones act on the normal and diseased heart, less is known about the actions of these peptides on blood vessels. Here we review the effects of these peptide hormones on normal blood vessels and highlight their vascular actions in the setting of experimental and clinical vascular injury. The cellular localization and signal transduction properties of the receptors for glucagon, GLP-1, GLP-2, and glucose-dependent insulinotropic polypeptide are discussed, with emphasis on endothelial cells and vascular smooth muscle cells. The actions of these peptides on the control of blood flow, blood pressure, angiogenesis, atherosclerosis, and vascular inflammation are reviewed with a focus on elucidating direct and indirect mechanisms of action. How these peptides traverse the blood-brain barrier is highlighted, with relevance to the use of GLP-1 receptor agonists to treat obesity and neurodegenerative disorders. Wherever possible, we compare actions identified in cell lines and primary cell culture with data from preclinical studies and, when available, results of human investigation, including studies in subjects with diabetes, obesity, and cardiovascular disease. Throughout the review, we discuss pitfalls, limitations, and challenges of the existing literature and highlight areas of controversy and uncertainty. The increasing use of peptide-based therapies for the treatment of diabetes and obesity underscores the importance of understanding the vascular biology of peptide hormone action.
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Affiliation(s)
- Gemma Pujadas
- Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mt. Sinai Hospital, University of Toronto, Toronto, ON M5G 1X5, Canada
| | - Daniel J Drucker
- Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mt. Sinai Hospital, University of Toronto, Toronto, ON M5G 1X5, Canada
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