Cardiovascular and renal outcomes of glucagon-like peptide 1 receptor agonists among patients with and without type 2 diabetes mellitus: A meta-analysis of randomized placebo-controlled trials

Tirzepatide and major adverse limb events: Insights from a multicenter real-world analysis in PAD and diabetes patients

AIMS

Peripheral artery disease (PAD) is a major diabetic complication and a leading cause of amputation. While GLP-1 receptor agonists (GLP-1 RAs) provide cardiovascular and limb protection, the impact of tirzepatide, a dual GLP-1/GIP receptor agonist, on major adverse limb events (MALEs) remains unclear. This study assessed tirzepatide's association with MALE risk in patients with PAD and diabetes using real-world data.

METHODS

This retrospective cohort study analyzed 8,046 propensity score-matched PAD patients with diabetes (4,023 on tirzepatide, 4,023 controls) from the TriNetX database. The primary outcome was MALEs, with secondary outcomes including all-cause mortality, acute stroke, acute myocardial infarction (AMI), and major adverse cardiovascular events (MACEs). Cox models and Kaplan-Meier curves were used for analysis.

RESULTS

Tirzepatide significantly reduced MALE risk (HR: 0.44, 95 % CI: 0.33-0.59, p < 0.001) and was associated with lower mortality, stroke, and MACEs. AMI risk was similar between groups (HR: 0.85, p = 0.29). Subgroup analyses confirmed consistent findings, except in those with prior stroke.

CONCLUSIONS

Tirzepatide significantly lowered MALE risk in PAD patients with diabetes, suggesting a potential therapeutic role. Further prospective studies are needed to validate these findings.

Melioidosis in people living with diabetes; clinical presentation, clinical course and implications for patient management

BACKGROUND

Despite the well-established link between diabetes mellitus and melioidosis, the precise impact of diabetes, its complications, and its therapy on the presentation and clinical course of melioidosis is incompletely defined. The influence of glycaemic control on the diverse clinical manifestations and the clinical course of melioidosis in patients with diabetes has also not been examined in detail.

METHODS

We examined all cases of culture-confirmed melioidosis in Far North Queensland, Australia between October 1, 2016, and April 30, 2024. We hoped to define the impact of diabetes, its control and its therapy on the patients' presentation and their clinical course.

RESULTS

There were 321 cases of culture-confirmed melioidosis during the study period; the patients' median (interquartile range (IQR)) age was 57 (46-69) years, 212/321 (66 %) were male, 130/321 (41 %) identified as First Nations Australians. Diabetes was the most common risk factor for melioidosis in the cohort (163/321, 51 %); in 19/163 (12 %) this was a new diagnosis. The median (IQR)) glycosylated haemoglobin prior to presentation was 9.1 % (7.2-11.5) and 96/162 (59 %) with complete data had established macrovascular or microvascular complications. People with diabetes were more likely - than people without diabetes - to have involvement of the liver (odds ratio (OR) 95 % confidence interval (CI): 9.68 (2.21-42.46), p = 0.003), the spleen (OR (95 % CI): 7.32 (1.64-32.80), p = 0.009) or to have disseminated disease (OR (95 % CI): 2.93 (1.26-6.78), p = 0.01). However, people with diabetes were no more likely than people without diabetes to require intensive care unit admission (OR (95 % CI): 0.82 (0.47-1.42), p = 0.48) or to die before hospital discharge (12/163 (7 %) versus 19/158 (12 %), OR (95 % CI): 0.58 (0.27-1.24), p = 0.16). Only 58/163 (36 %) with diabetes had specialist endocrinology review during their hospitalisation and only 22/72 (31 %) with accessible data had good glycaemic control (glycosylated haemoglobin ≤7 %) in the 12 months after discharge, increasing their risk of subsequent diabetic complications. Of the 151 people with diabetes surviving their hospitalisation, 26 (17 %) died, at a median (IQR) of 1.0 (0.40-4.1) years after discharge. Of the individuals with diabetes who had completed five years of follow up, 21/60 (35 %) had died at a median (IQR) age of 67 (51-84) years.

CONCLUSIONS

Individuals with diabetes and melioidosis are more likely to have liver and spleen abscesses and disseminated disease than individuals without diabetes, manifestations that appear to be linked directly to glycaemic control. In Australia's well-resourced health system <10 % of patients with diabetes and melioidosis will die from their infection. However, five-year all-cause mortality in individuals with diabetes who survive their melioidosis is greater than 30 %, emphasising the importance of close, holistic multidisciplinary follow-up to ensure their optimal long-term health outcomes.

Glucagon-like peptide-1 receptor agonism and end-organ protection

Identification of exendin-4 (a glucagon-like peptide 1 receptor agonist, GLP-1RA) in Gila monster venom may be regarded as one of the most serendipitous discoveries of recent times. GLP-1RAs are now an established therapeutic approach in type 2 diabetes (T2D), body weight management, and cardiovascular (CV) risk protection. Furthermore, there is a growing platform of evidence that GLP-1RA has extended benefit in renal, hepatic, respiratory, and neurological diseases. One can speculate on the biological advantage of exendin-4 to the Gila monster, but for humankind GLP-1RAs are peptides with significant potential to improve disease-related outcomes. We report on the latest evidence and mechanisms for GLP-1RA-mediated end-organ protection that uniquely highlight its future development potential across multiple disease areas.

Evaluations of metabolic and innate immunity profiles in subjects with familial hypercholesterolemia with or without subclinical atherosclerosis

BACKGROUND

Familial hypercholesterolemia (FH) is a genetic condition characterized by high low-density lipoprotein cholesterol (LDL-C). The presence of risk modifiers could promote the atherosclerotic injury beyond LDL-C. Our aim was to evaluate metabolic and innate immunity profiles in FH subjects with or without subclinical atherosclerosis.

METHODS

In this cross-sectional observational study, we evaluated 211 genetically confirmed FH subjects on LDL-C target and without cardiovascular diseases. Biochemical analyses, LDL-C burden (LCB) calculation and vascular profile evaluation were obtained from all subjects. Study population was divided into two groups according to subclinical atherosclerosis: the subclinical atherosclerosis (SA) group and non-subclinical atherosclerosis (NSA) group.

RESULTS

SA group had higher LDL-C at diagnosis (288.35 ± 24.52 vs 267.92 ± 23.86, p < 0.05) and LCB (13,465.84 ± 3617.46 vs 10,872.63 ± 3594.7, p < 0.001) than NSA group. SA group had higher white blood cell count (WBCC, 6.9 ± 1.66 vs 6.1 ± 1.16), neutrophil count (NC, 4.2 ± 1.3 vs 3.6 ± 1.11), monocyte count (MC, 0.8 ± 0.2 vs 0.4 ± 0.1), triglyceride to high-density lipoprotein ratio (TG/HDL, 1.73 ± 0.72 vs 1.45 ± 0.69), triglyceride-glucose index (TyG, 8.29 ± 0.35 vs 8.01 ± 0.33) than NSA group (p value for all < 0.01). Multivariate logistic regression analysis showed that LCB (p < 0.01), WBCC (p < 0.01), NC (p < 0.05), MC (p < 0.05) were associated with subclinical atherosclerosis. Simple linear regression analyses showed that LCB was associated with WBCC, NC, MC (p value for all < 0.01).

CONCLUSION

An increased LCB and an impaired innate immunity profile were found in FH subjects with subclinical atherosclerosis and they were independently associated with atherosclerotic injury. LCB could modulate the innate immunity profile.

Overview of diabetes agents in cardiovascular disease: it takes an orchestra to play Tchaikovsky in symphony

PURPOSE OF REVIEW

The aim of this review was to discuss the use and concerns of diabetes agents, clinical targets, and key aspects to be considered in the management of patients with type 2 diabetes mellitus (T2DM), and at high risk or established cardiovascular disease (CVD).

RECENT FINDINGS

The recent European and American guidelines recommended SGLT2 inhibitors and GLP-1 receptor agonists as the preferred first-line diabetes agents in patients with T2DM and CVD. This is a paradigm shift from using metformin as first-line therapy. Amid their widespread use, however, there are also concerns about their side effects. With the rapidly growing diabetes regimens available, questions arise about how best to approach the management of patients with T2DM and CVD.

SUMMARY

To reduce CVD morbidity and mortality in patients with T2DM and at high or very high risk for CVD, the two key diabetes agents SGLT2i and/or GLP1-based therapies should be offered. Although lacking cardiovascular benefit, other diabetes agents remain necessary for many patients with T2DM for their glucocentric effects; Metformin and pioglitazone are useful in severe insulin resistance, while insulin therapy is often necessary in advanced diabetes; GLP1-RA is cautioned in patients with active gastrointestinal and mental health conditions, while DPP4 inhibitor is likely a well tolerated option in a challenging psychosocial setting. Other important aspects that should be considered include obesity, chronic kidney disease, women's cardiovascular health, and psychosocial factors.

Critical Appraisal of Pharmaceutical Therapy in Diabetic Cardiomyopathy-Challenges and Prospectives

Diabetes mellitus (DM) is a multifaceted disorder with a pandemic spread and a remarkable burden of cardiovascular mortality and morbidity. Diabetic cardiomyopathy (DBCM) has been increasingly recognized as the development of cardiac dysfunction, which is accompanied by heart failure (HF) symptoms in the absence of obvious reasons like ischemic heart disease, hypertension, or valvulopathies. Several pathophysiological mechanisms have been proposed, including metabolic disorders (e.g., glycation products), oxidative stress, low-grade inflammation, mitochondrial dysfunction, etc., which should guide the development of new therapeutic strategies. Up to now, HF treatment has not differed between patients with and without diabetes, which limits the expected benefits despite the high cardiovascular risk in the former group. However, DBCM patients may require different management, which prioritize anti-diabetic medications or testing other novel therapies. This review aims to appraise the challenges and prospectives of the individualized pharmaceutical therapy for DBCM.

Enrollment of Females in Randomized Trials for Glucagon-Like Peptide 1 Receptor Agonists: A Systematic Review

Background

Randomized controlled trials (RCTs) of glucagon-like peptide 1 receptor agonists (GLP-1RAs) form the basis for therapeutic recommendations for both males and females. Historically, females have been significantly underrepresented in RCTs.

Objectives

The authors sought to determine the trends of representation of females in GLP-1RA RCTs from 2007 to 2024.

Methods

We reviewed eligible studies and extracted important variables. The proportion of females among the total participants was obtained per study. This was compared over time (year) of publication and over mean age of participants. This proportion was also compared between specific types of GLP-1RA received, diabetes status, indication of therapy, and concurrent comorbidities. Participation to prevalence ratio was used to compare participation of women in clinical trials to the actual numbers of females affected by disease.

Results

We observed a declining trend in the proportion of females enrolled in RCTs compared to men (np-trend z = -2.29, P = 0.022). Studies with a higher proportion of females were those done among patients without diabetes mellitus (42% vs 39%, z = 4.53, P < 0.01), and those who were obese (42%, P < 0.01). Females were also fairly represented among smaller RCTs done in patients with heart failure (42%, P < 0.01) and chronic kidney disease (46%, P < 0.01). There was a significant underrepresentation of females in coronary heart disease (35%, P < 0.01).

Conclusions

There is a declining trend in the proportion of females enrolled in GLP-1RA RCTs compared to men. Females are fairly represented among RCTs done in heart failure and chronic kidney disease, however, significantly underrepresented for studies on coronary heart disease.

Glucagon-like Peptide 1 Receptor Agonists in Cardio-Oncology: Pathophysiology of Cardiometabolic Outcomes in Cancer Patients

Cancer patients, especially long cancer survivors, are exposed to several cardio-metabolic diseases, including diabetes, heart failure, and atherosclerosis, which increase their risk of cardiovascular mortality. Therapy with glucagon-like peptide 1 (GLP1) receptor agonists demonstrated several beneficial cardiovascular effects, including atherosclerosis and heart failure prevention. Cardiovascular outcome trials (CVOTs) suggest that GLP-1 RA could exert cardiorenal benefits and systemic anti-inflammatory effects in patients with type-2 diabetes through the activation of cAMP and PI3K/AkT pathways and the inhibition of NLRP-3 and MyD88. In this narrative review, we highlight the biochemical properties of GLP-1 RA through a deep analysis of the clinical and preclinical evidence of the primary prevention of cardiomyopathies. The overall picture of this review encourages the study of GLP-1 RA in cancer patients with type-2 diabetes, as a potential primary prevention strategy against heart failure and atherosclerosis.

Comparative Effectiveness of Bariatric Metabolic Surgery Versus Glucagon-Like Peptide-1 Receptor Agonists on Cardiovascular Outcomes and Mortality: A Meta-Analysis

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality worldwide, particularly in individuals with obesity and type 2 diabetes mellitus (T2DM). This meta-analysis aimed to compare the effectiveness of bariatric metabolic surgery (BMS) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) on cardiovascular outcomes and mortality in patients with obesity. A comprehensive literature search was conducted in Medline, Embase, and Cochrane CENTRAL from inception to September 15, 2024. Four observational studies meeting the inclusion criteria were analyzed, comprising a total of 247,000 patients. The primary outcomes were major adverse cardiovascular events (MACE) and all-cause mortality. Random effects models were used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI). The results showed that BMS was associated with a significantly lower risk of MACE compared to GLP-1RAs (RR: 0.71, 95% CI: 0.56-0.90, p = 0.004), indicating a 29% reduction in MACE risk. Additionally, BMS demonstrated a 25% reduction in all-cause mortality risk (RR: 0.75, 95% CI: 0.65-0.87, p < 0.0001). These findings suggest that BMS offers superior cardiovascular protection and improved survival outcomes compared to GLP-1RAs in obese patients. The observed benefits may be attributed to more significant reductions in body mass index (BMI) and improvements in metabolic parameters achieved through surgical intervention. However, the limitations of this study, including its observational nature and the limited number of included studies, underscore the need for further research, particularly randomized controlled trials (RCTs), to confirm these findings and guide clinical decision-making in obesity management.

Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists: Exploring Their Impact on Diabetes, Obesity, and Cardiovascular Health Through a Comprehensive Literature Review

Glucagon-like peptide-1 receptor agonists (GLP-1-RAs) are a novel class of medications promising for treating type 2 diabetes mellitus (T2DM) and obesity-related conditions such as cardiovascular disease (CVD) and non-alcoholic fatty liver disease (NAFLD). This comprehensive literature review examines available research on these medications, focusing on their mechanisms of action, clinical effectiveness, safety profiles, and socioeconomic implications. A comprehensive search was performed using the PubMed, EMBASE, and Cochrane Library databases. Although initially developed for glucose management, these drugs have also demonstrated efficacy in promoting weight loss and reducing the risk of CVD. GLP-1-RAs function similarly to naturally occurring incretins. They stimulate insulin secretion in response to glucose levels, inhibit glucagon release, delay stomach emptying, and generate a sense of fullness via brain pathways. Head-to-head clinical studies have indicated that GLP-1-RAs outperform conventional antidiabetic medicines in terms of glycemic management and weight reduction. According to cardiovascular outcome studies, various drugs in this category have been found to reduce the frequency of severe adverse cardiovascular events. A common side effect is gastrointestinal toxicity, which can be mitigated by gradually increasing the dose. Personalized treatment is likely because the effectiveness, safety, and dose regimens of currently available GLP-1-RAs differ. GLP-1-RAs are a superior choice for patients with T2DM, especially those who already have CVD or require weight-control support. The high cost of these drugs creates hurdles to access and fair healthcare. Current research mainly focuses on increasing therapeutic uses and producing orally delivered medicines with greater potency and bioavailability. Integrating GLP-1-RAs into clinical practice can enhance patient outcomes and reduce the community burden of cardiometabolic disease.