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He J, Xi Y, Lam H, Du K, Chen D, Dong Z, Xiao J. Effect of Intensive Glycemic Control on Myocardial Infarction Outcome in Patients with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis. J Diabetes Res 2023; 2023:8818502. [PMID: 36873813 PMCID: PMC9984264 DOI: 10.1155/2023/8818502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND The effect of intensive glucose-lowering treatment on the risk of cardiovascular events in type 2 diabetes remains uncertain, especially the effect on the occurrence of myocardial infarction in patients with type 2 diabetes is still unclear. The purpose of this study was to conduct a systematic review and meta-analysis of relevant RCTs. METHODS We performed a systematic review of randomized clinical trials (RCTS) and observational studies relevant to this study question. We searched the PubMed and Cochrane databases until June 2022. RESULTS We included data on 14 RCTs and 144,334 patients, all of whom had type 2 diabetes. When all studies were considered, intensive glucose-lowering treatment significantly reduced the incidence of MI compared with conventional therapy and the total OR value is 0.90 (CI 0.84, 0.97; P = 0.004) when considering all the studies. When the target value of intensive glucose-lowering treatment was considered as HbA1c decrease of more than 0.5%, there was no significant protective effect on MI, the total OR value is 0.88 (CI 0.81, 0.96; P = 0.003). When considering all available RCTS, the intensive glucose-lowering treatment group had a protective effect for MACE compared to the conventional treatment group, and the total OR value is 0.92 (CI 0.88, 0.96; P < 0.00001). In the available RCTs, for the patients with a history of prior CAD, the total OR value is 0.94 (CI 0.89, 0.99; P = 0.002). And there was no difference in the incidence of hypoglycemic events between the intensive and conservative treatment groups. CONCLUSION Our data support the positive protective effect of glucose-lowering therapy on MI in patients with T2DM, but there is no significant effect of intensive glucose-lowering. In addition, we found no greater protective effect of enhanced glucose control in the HbA1c reduction of more than 0.5%, and no difference in the incidence of adverse events compared with the HbA1c reduction of less than 0.5%.
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Affiliation(s)
- Jiading He
- Department of Cardiology, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
- Department of The First Clinical Medical College, Jinan University, Guangzhou, China
| | - Yangbo Xi
- Department of Cardiology, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
- Department of The First Clinical Medical College, Jinan University, Guangzhou, China
| | - Hingcheung Lam
- Department of Cardiology, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
- Department of The First Clinical Medical College, Jinan University, Guangzhou, China
| | - Keyi Du
- Department of Cardiology, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
- Department of The First Clinical Medical College, Jinan University, Guangzhou, China
| | - Dongping Chen
- Central Laboratory, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
| | - Zhihui Dong
- Central Laboratory, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
| | - Jianmin Xiao
- Department of Cardiology, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
- Central Laboratory, The Dongguan Affiliated Hospital of Jinan University, Binhaiwan Central Hospital of Dongguan, Dongguan, China
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Liu T, Li R, Wang X, Gao X, Zhang X. Benefits of SGLT2 inhibitors combining with renin-angiotensin-system blockers on cardiovascular outcomes in chronic kidney disease patients: A systemic review and meta-analysis. Med Clin (Barc) 2021; 159:65-72. [PMID: 34872768 DOI: 10.1016/j.medcli.2021.09.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/28/2021] [Accepted: 09/02/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Efficacy of sodium-glucose cotransporter 2 (SGLT2) inhibitors in combination with renin-angiotensin-system (RAS) blockers for CKD remains controversial. We conducted this meta-analysis to explore the effect of SGLT2 inhibitors combining with RAS blockers on cardiovascular outcomes in chronic kidney disease (CKD) patients. METHODS We searched Embase, PubMed, Web of Science, and Cochrane Library databases with the following keywords. "Renal Insufficiency, Chronic" or "Diabetic Nephropathies" and "Sodium-glucose cotransporter 2 inhibitors". We included randomized controlled trials (RCTs) based on angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) therapy. The outcome events included cardiac and renal outcomes and other adverse events. This study is registered with PROSPERO: CRD42020218337. RESULTS Ten RCTs including 16,983 CKD patients met the inclusion criteria. Compared with placebo plus RAS blockers, SGLT2 inhibitors plus RAS blockers significantly reduced cardiovascular mortality and heart failure-related hospitalization rates (RR=0.78, 95% CI: 0.66-0.91, p=0.002; RR=0.7, 95% CI: 0.61-0.8, p=0.000). We also performed trials sequential analysis (TSA) and the results indicated that our results are reliable. Additionally, it significantly reduced the 24-h urinary albumin excretion rate (24hUAE) and the creatinine elevation rate (WMD=-0.19, 95% CI: -0.24 to -0.14; RR=0.61, 95% CI: 0.51-0.74, p=0.000), delayed progression to end-stage renal disease (ESRD) (RR=0.69, 95% CI: 0.59-0.81, p=0.000). Further, it had no significant effect on the incidence of renal-related adverse events or renal-related mortality. Although it decreased the estimated glomerular filtration rate (eGFR) (WMD=-5.4, 95% CI: -7.24 to -3.57), this effect was reversible. CONCLUSIONS These data provide a well-document testimonial of the benefits of the combined use of SGLT2 inhibitors and RAS blockers for cardiovascular and renal outcomes in CKD patients.
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Affiliation(s)
- Ting Liu
- Department of Nephrology, The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Rui Li
- Shanxi Medical University, Taiyuan, China
| | | | | | - Xiaodong Zhang
- Department of Nephrology, The First Hospital of Shanxi Medical University, Taiyuan, China.
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Does Empagliflozin Modulate Leukocyte-Endothelium Interactions, Oxidative Stress, and Inflammation in Type 2 Diabetes? Antioxidants (Basel) 2021; 10:antiox10081228. [PMID: 34439476 PMCID: PMC8389001 DOI: 10.3390/antiox10081228] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/21/2021] [Accepted: 07/27/2021] [Indexed: 11/17/2022] Open
Abstract
Sodium-glucose co-transporter 2 inhibitors (iSGLT2) have been linked to cardiovascular risk reduction in patients with type 2 diabetes (T2D). However, their underlying molecular mechanisms remain unclear. This study aimed to evaluate the effects of empagliflozin, a novel potent and selective iSGLT-2, on anthropometric and endocrine parameters, leukocyte–endothelium interactions, adhesion molecules, ROS production, and NFkB-p65 transcription factor expression. According to standard clinical protocols, sixteen T2D patients receiving 10 mg/day of empagliflozin were followed-up for 24 weeks. Anthropometric and analytical measurements were performed at baseline, 12 weeks, and 24 weeks. Interactions between polymorphonuclear leukocytes and human umbilical vein endothelial cells (HUVECs), serum levels of adhesion molecules (P-Selectin, VCAM-1 and ICAM-1) and pro-inflammatory cytokines (TNF-α, IL-1β and IL-6), mitochondrial ROS levels, antioxidant enzymes (SOD1 and GPX1), and NFkB-p65 were measured. We observed a decrease in body weight, BMI, and HbA1C levels from 12 weeks of treatment, which became more pronounced at 24 weeks and was accompanied by a significant reduction in waist circumference and glucose. Leukocyte–endothelium interactions were reduced due to an enhancement in the leukocyte rolling velocity from 12 weeks onwards, together with a significant decrease in leukocyte rolling flux and adhesion at 24 weeks. Accordingly, a significant decrease in ICAM-1 levels, mitochondrial ROS levels, and IL-6 and NFkB-p65 expression was observed, as well as an increase in SOD1. This pilot study provides evidence of the anti-inflammatory and antioxidant properties of empagliflozin treatment in humans, properties which may underlie its beneficial cardiovascular effects.
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Sodium-Glucose Cotransporter-2 Inhibitors for Treatment of Nonalcoholic Fatty Liver Disease: A Meta-Analysis of Randomized Controlled Trials. Metabolites 2020; 11:metabo11010022. [PMID: 33396949 PMCID: PMC7823667 DOI: 10.3390/metabo11010022] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/25/2020] [Accepted: 12/28/2020] [Indexed: 12/13/2022] Open
Abstract
Recent randomized controlled trials (RCTs) tested the efficacy of sodium-glucose cotransporter-2 (SGLT-2) inhibitors to specifically treat nonalcoholic fatty liver disease (NAFLD). We systematically searched three electronic databases (up to 31 October 2020) for identifying placebo-controlled or head-to-head RCTs that used SGLT-2 inhibitors for treatment of NAFLD. No published RCTs with paired liver biopsy data were available for the meta-analysis. Primary outcome measures were changes in serum liver enzyme levels and liver fat content on imaging techniques. Overall, we included a total of twelve RCTs testing the efficacy of dapagliflozin (n = six RCTs), empagliflozin (n = three RCTs), ipragliflozin (n = two RCTs) or canagliflozin (n = one RCT) to specifically treat NAFLD for a median period of 24 weeks with aggregate data on 850 middle-aged overweight or obese individuals with NAFLD (90% with type 2 diabetes). Compared to placebo/reference therapy, treatment with SGLT-2 inhibitors significantly decreased serum alanine aminotransferase (weighted mean differences (WMD): −10.0 IU/L, 95%CI −12.2 to −7.79 IU/L; I2 = 10.5%) and gamma-glutamyltransferase levels (WMD: −14.49 IU/L, 95%CI −19.35 to −9.63 IU/L, I2 = 38.7%), as well as the absolute percentage of liver fat content on magnetic resonance-based techniques (WMD: −2.05%, 95%CI −2.61 to −1.48%; I2 = 0%). In conclusion, SGLT-2 inhibitors seem to be a promising treatment option for NAFLD.
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Sarafidis P, Ferro CJ, Morales E, Ortiz A, Malyszko J, Hojs R, Khazim K, Ekart R, Valdivielso J, Fouque D, London GM, Massy Z, Ruggenenti P, Porrini E, Wiecek A, Zoccali C, Mallamaci F, Hornum M. SGLT-2 inhibitors and GLP-1 receptor agonists for nephroprotection and cardioprotection in patients with diabetes mellitus and chronic kidney disease. A consensus statement by the EURECA-m and the DIABESITY working groups of the ERA-EDTA. Nephrol Dial Transplant 2020; 34:208-230. [PMID: 30753708 DOI: 10.1093/ndt/gfy407] [Citation(s) in RCA: 128] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 12/10/2018] [Indexed: 12/20/2022] Open
Abstract
Chronic kidney disease (CKD) in patients with diabetes mellitus (DM) is a major problem of public health. Currently, many of these patients experience progression of cardiovascular and renal disease, even when receiving optimal treatment. In previous years, several new drug classes for the treatment of type 2 DM have emerged, including inhibitors of renal sodium-glucose co-transporter-2 (SGLT-2) and glucagon-like peptide-1 (GLP-1) receptor agonists. Apart from reducing glycaemia, these classes were reported to have other beneficial effects for the cardiovascular and renal systems, such as weight loss and blood pressure reduction. Most importantly, in contrast to all previous studies with anti-diabetic agents, a series of recent randomized, placebo-controlled outcome trials showed that SGLT-2 inhibitors and GLP-1 receptor agonists are able to reduce cardiovascular events and all-cause mortality, as well as progression of renal disease, in patients with type 2 DM. This document presents in detail the available evidence on the cardioprotective and nephroprotective effects of SGLT-2 inhibitors and GLP-1 analogues, analyses the potential mechanisms involved in these actions and discusses their place in the treatment of patients with CKD and DM.
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Affiliation(s)
- Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Enrique Morales
- Department of Nephrology, Hospital Universitario 12 de Octubre and Research Institute i+12, Madrid, Spain
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warsaw, Poland
| | - Radovan Hojs
- Department of Nephrology, University Medical Center and Faculty of Medicine, Maribor University, Maribor, Slovenia
| | - Khaled Khazim
- Department of Nephrology and Hypertension, Galilee Medical Center, Nahariya, Israel
| | - Robert Ekart
- Department of Nephrology, University Medical Center and Faculty of Medicine, Maribor University, Maribor, Slovenia
| | - Jose Valdivielso
- Vascular and Renal Translational Research Group, Institut de Recerca Biomedica de Lleida, IRBLleida, Lleida and RedInRen, ISCIII, Spain
| | - Denis Fouque
- Department of Nephrology, Centre Hospitalier Lyon Sud, University of Lyon, Lyon, France
| | | | - Ziad Massy
- Hopital Ambroise Paré, Paris Ile de France Ouest (UVSQ) University, Paris, France
| | - Petro Ruggenenti
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Nephrology and Dialysis Unit, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Esteban Porrini
- Faculty of Medicine, University of La Laguna, Instituto de Tecnología Biomédicas (ITB) Hospital Universitario de Canarias, Tenerife, Canary Islands, Spain
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
| | - Mads Hornum
- Department of Nephrology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
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Schernthaner G, Schernthaner GH. The right place for metformin today. Diabetes Res Clin Pract 2020; 159:107946. [PMID: 31778746 DOI: 10.1016/j.diabres.2019.107946] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/22/2019] [Indexed: 02/06/2023]
Abstract
Metformin is the most widely used glucose lowering drug worldwide in the treatment of patients with type 2 diabetes, since we have experience with this drug for more than 60 years about the efficacy and safety. Metformin is very effective in HbA1c lowering associated with some weight loss, but does not increase risk for hypoglycemia. At the moment all guidelines in the world recommend to use metformin in monotherapy in patients with newly diagnosed diabetes or in combination with other antidiabetic drugs with documented CV (and renal) benefit in cardiovascular outcome trials (CVOT). Although a randomized placebo controlled CVOT with metformin is lacking, many observational studies in patients with coronary heart disease, heart failure and chronic kidney disease have demonstrated consistent beneficial effects. A recent metanalysis of 26 observational studies including 815 839 patients showed that metformin use was associated with a significantly lower rate of all-cause mortality (HR: 0.74; 95% CI: 0.68-0.81). Whether this very consistent reduction of all-cause mortality is related to the incidence/outcome of several cancers has still to be investigated. In the future early combination therapy of metformin e.g. with SGLT-2 inhibitors should be more often used.
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Affiliation(s)
- Guntram Schernthaner
- Rudolfstiftung Hospital & Medical University of Vienna, Department of Medicine II, Vienna, Austria; Medical University of Vienna, Department of Medicine II, Vienna, Austria
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Ninčević V, Omanović Kolarić T, Roguljić H, Kizivat T, Smolić M, Bilić Ćurčić I. Renal Benefits of SGLT 2 Inhibitors and GLP-1 Receptor Agonists: Evidence Supporting a Paradigm Shift in the Medical Management of Type 2 Diabetes. Int J Mol Sci 2019; 20:ijms20235831. [PMID: 31757028 PMCID: PMC6928920 DOI: 10.3390/ijms20235831] [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] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 11/13/2019] [Accepted: 11/18/2019] [Indexed: 01/09/2023] Open
Abstract
Diabetic nephropathy (DN) is one of the most perilous side effects of diabetes mellitus type 1 and type 2 (T1DM and T2DM).). It is known that sodium/glucose cotransporter 2 inhibitors (SGLT 2i) and glucagone like peptide-1 receptor agonists (GLP-1 RAs) have renoprotective effects, but the molecular mechanisms are still unknown. In clinical trials GLP-1 analogs exerted important impact on renal composite outcomes, primarily on macroalbuminuria, possibly through suppression of inflammation-related pathways, however enhancement of natriuresis and diuresis is also one of possible mechanisms of nephroprotection. Dapagliflozin, canagliflozin, and empagliflozin are SGLT2i drugs, useful in reducing hyperglycemia and in their potential renoprotective mechanisms, which include blood pressure control, body weight loss, intraglomerular pressure reduction, and a decrease in urinary proximal tubular injury biomarkers. In this review we have discussed the potential synergistic and/or additive effects of GLP 1 RA and SGLT2 inhibitors on the primary onset and progression of kidney disease, and the potential implications on current guidelines of diabetes type 2 management.
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Affiliation(s)
- Vjera Ninčević
- Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000 Osijek, Croatia; (V.N.); (T.O.K.); (H.R.)
- Department of Pharmacology and Biochemistry, Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia
| | - Tea Omanović Kolarić
- Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000 Osijek, Croatia; (V.N.); (T.O.K.); (H.R.)
- Department of Pharmacology and Biochemistry, Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia
| | - Hrvoje Roguljić
- Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000 Osijek, Croatia; (V.N.); (T.O.K.); (H.R.)
- Department for Cardiovascular Disease, University Hospital Osijek, 4, 31000 Osijek, Croatia
| | - Tomislav Kizivat
- Clinical Institute of Nuclear Medicine and Radiation Protection, University Hospital Osijek, 31000 Osijek, Croatia;
- Department for Nuclear Medicine and Oncology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek; J. Huttlera 4, 31000 Osijek, Croatia
| | - Martina Smolić
- Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000 Osijek, Croatia; (V.N.); (T.O.K.); (H.R.)
- Department of Pharmacology and Biochemistry, Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Crkvena 21, 31000 Osijek, Croatia
| | - Ines Bilić Ćurčić
- Department of Pharmacology, Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000 Osijek, Croatia; (V.N.); (T.O.K.); (H.R.)
- Department of Diabetes, Endocrinology and Metabolism Disorders, University Hospital Osijek, 31000 Osijek, Croatia
- Correspondence:
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Wang X, Cao Y, Wu Y, Yang C, Song J, Tian Y, Wang M, Li M, Wu Y, Hu Y. The prescription pattern of initial treatment for type 2 diabetes in Beijing from 2011 to 2015. Medicine (Baltimore) 2019; 98:e14370. [PMID: 30813137 PMCID: PMC6408070 DOI: 10.1097/md.0000000000014370] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The purpose of this study was to describe the prescription pattern of initial treatment for type 2 diabetes (T2DM) in Beijing from 2011 to 2015.We selected 790,339 newly diagnosed outpatients with T2DM from the Beijing Medical Claim Data for Employees database between January 2011 and December 2015. The percentages of different treatments and agents were calculated from the patients' 1st prescriptions. Subgroup analyses were conducted for primary, secondary, and tertiary hospital settings.The initial treatments given to 57.7%, 30.7%, and 11.7% of patients were oral hypoglycemic agent (OHA) monotherapy, OHA polytherapy, and insulin, respectively. Alpha-glucosidase inhibitors (AGIs) (43.0%) were the most commonly used agents for monotherapy, followed by metformin (35.5%) and sulfonylureas (14.9%). AGIs were most commonly used in primary hospitals (52.0%), while metformin was prescribed most often in secondary (37.6%) and tertiary (41.8%) hospitals. From 2011 to 2015, there were increases in the use of AGIs (40.1-41.1%, P < .001) and metformin (34.0-40.4%, P < .001), but a decrease in the use of sulfonylureas (18.1-12.8%, P < .001). Similar trends were seen in the different hospital settings. Metformin plus an AGI, a sulfonylurea plus an AGI, and metformin plus a sulfonylurea were the most common OHA polytherapy combinations. The use of metformin plus an AGI increased from 13.8% in 2011 to 19.7% in 2015 (P < .001), while the use of a sulfonylurea plus an AGI, and metformin plus a sulfonylurea, did not change significantly.Half of newly diagnosed patients with T2DM received an initial treatment of OHA monotherapy. Although the use of metformin increased from 2011 to 2015, both AGIs and metformin were the most commonly prescribed agents. The patterns differed from those of most other countries and identification of the underlying reasons will require further investigation.
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Affiliation(s)
- Xiaowen Wang
- Department of Epidemiology and Biostatistics, School of Public Health
| | - Yaying Cao
- Department of Epidemiology and Biostatistics, School of Public Health
| | - Yao Wu
- Department of Epidemiology and Biostatistics, School of Public Health
| | - Chao Yang
- Department of Epidemiology and Biostatistics, School of Public Health
| | - Jing Song
- Department of Epidemiology and Biostatistics, School of Public Health
| | - Yaohua Tian
- Department of Epidemiology and Biostatistics, School of Public Health
| | - Mengying Wang
- Department of Epidemiology and Biostatistics, School of Public Health
| | - Man Li
- Department of Epidemiology and Biostatistics, School of Public Health
| | - Yiqun Wu
- Department of Epidemiology and Biostatistics, School of Public Health
| | - Yonghua Hu
- Department of Epidemiology and Biostatistics, School of Public Health
- Medical Informatics Center, Peking University Health Science Center, Beijing, China
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Winell K, Arffman M, Pietilä A, Salomaa V. Regional differences in the incidence of diabetic cardiovascular events reflect the quality of care. SCAND CARDIOVASC J 2019; 52:232-237. [PMID: 30614294 DOI: 10.1080/14017431.2018.1497198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Diabetic patients have two-fold excess risk of cardiovascular complications (CVCs). To compare the treatment quality of diabetic patients we compared the incidence of CVCs between the five university hospital districts (UHDs) in Finland. DESIGN The study population comprised all persons with diabetes in Finland since 1964. They were followed up for the incidence of first acute coronary syndrome (ACS) and first ischemic stroke (IS) using the National Hospital Discharge Register and the National Causes of Death Register data between the years 2000 and 2011. Incidence differences among diabetic patients were also compared with corresponding results in the total population. The main analysis tool was Poisson regression adjusted for age, sex and study year. The UHD of Helsinki was used as the reference category. RESULTS In the diabetic population the risk for ACS exceeded the reference significantly in three UHDs ranging from 1.03 (95% CI 0.89-1.19) to 1.70 (1.46-1.97). The incidence of IS exceeded the reference in two UHDs ranging from 1.01 (0.89-1.15) to 1.36 (1.18-1.56). These differences were similar to the corresponding figures in the total population. Differences between the UHDs remained stable over time. CONCLUSIONS We found major and stable differences in the incidence of ACS and IS between the UHDs among patients with diabetes. The differences result from several factors influencing the risk of these complications, including the treatment. These differences tended to be larger than the corresponding differences in the total population, which suggests that there is potential to prevent CVCs by improving diabetes care.
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Affiliation(s)
- Klas Winell
- a THL - National Institute of Health and Welfare , Helsinki , Finland
| | - Martti Arffman
- a THL - National Institute of Health and Welfare , Helsinki , Finland
| | - Arto Pietilä
- a THL - National Institute of Health and Welfare , Helsinki , Finland
| | - Veikko Salomaa
- a THL - National Institute of Health and Welfare , Helsinki , Finland
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Scheen AJ. The safety of empagliflozin plus metformin for the treatment of type 2 diabetes. Expert Opin Drug Saf 2018; 17:837-848. [PMID: 30068236 DOI: 10.1080/14740338.2018.1497159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Metformin is the first-line glucose-lowering medication in type 2 diabetes mellitus (T2DM), but it generally requires soon or later the addition of a second-line therapy, among which a sodium-glucose cotransporter type 2 (SGLT-2) inhibitor, to reach and maintain adequate glucose control. Areas covered: This narrative review provides an analysis of both efficacy and safety of a dual therapy combining metformin and empagliflozin, a SGLT-2 inhibitor that has proven its' potential to reduce major cardiovascular (CV) events, mortality, and renal outcomes in patients with T2DM and established CV disease. Pharmacokinetic studies showed the absence of drug-drug interactions and demonstrate bioequivalence between fixed-dose combination (FDC) and individual tablets of empagliflozin and metformin. Focus will be put on the use of this dual therapy in special populations. Expert opinion: The addition of empagliflozin to metformin therapy improves glucose control, with a minimal risk of hypoglycemia, while reducing body weight and arterial blood pressure. EMPA-REG OUTCOME showed that this combined therapy may be used in patients with established CV disease or heart failure. However, caution may be required in fragile elderly patients and in patients with severe impaired renal function. Further post-marketing surveillance is recommended to demonstrate long-term safety. FDC may improve adherence.
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Affiliation(s)
- André J Scheen
- a Division of Diabetes Nutrition and Metabolic Disorders, Department of Medicine, (B35) , University of Liège, CHU Sart Tilman , Liege , Belgium.,b Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM) , University of Liège, CHU Sart Tilman , Liège , Belgium
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Thuesen ACB, Vaag A. Perspectives on diabetes mortality as the result of residual confounding and reverse causality by common disease. Diabetes Obes Metab 2018; 20:1342-1349. [PMID: 29381250 DOI: 10.1111/dom.13238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/16/2018] [Accepted: 01/24/2018] [Indexed: 12/17/2022]
Abstract
Type 2 diabetes (T2D) is associated with major global health burdens, including 2 to 4 times increased rates of morbidity and mortality from cardiovascular disease. However, T2D remains an exclusion diagnosis in individuals with arbitrarily elevated blood-glucose levels. While it is well-established that diabetes is associated with an elevated risk of cardiovascular disease and cancer, it has recently been shown that heart failure and cancer may precede, and even contribute to, the development of T2D. In the present review, we have summarized these findings and discuss their potential implications for our understanding of the T2D disease entity, including its treatment and associated increased mortality. We suggest that the existence of a hitherto unrecognized distinct T2D subtype, secondary to heart failure and/or cancer, may substantially contribute to the excess mortality reported in T2D patients with mild disease. Treatment and clinical care of this subtype needs to be defined separately from the general T2D phenotype.
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Affiliation(s)
| | - Allan Vaag
- Cardiovascular and Metabolic Disease (CVMD) Translational Medicine Unit, Early Clinical Development, IMED Biotech Unit, AstraZeneca, Gothenburg, Sweden
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Hasan F, Hasan B. Antidiabetic medications and mortality reduction: a shift from surrogate to clinical endpoints. Ther Adv Endocrinol Metab 2017; 8:173-174. [PMID: 29238516 PMCID: PMC5721968 DOI: 10.1177/2042018817737955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
INTRODUCTION Novelties in the management of type 2 diabetes are dominated by the commercialisation of new glucose-lowering agents, which offer alternatives to older antidiabetic medications, and by the publication of several prospective placebo-controlled outcome trials, which demonstrated not only cardiovascular safety but also cardiovascular and renal protection with some new medications. Areas covered: Updates regarding the use of glucose-lowering agents are discussed from a clinical point of view. Some new viewpoints concern older antidiabetic agents such as metformin, sulfonylureas and glitazones whose benefit-risk balance has been revisited, especially in high risk patients. The recent data regarding DPP-4 inhibitors (gliptins) focused on the safety profile of this pharmacological class, including in patients with impaired renal function. The highlight concerns the cardiovascular (and renal) protection by some GLP-1 receptor agonists (liraglutide, semaglutide) and SGLT2 inhibitors (empagliflozin, canagliflozin) in patients with high cardiovascular risk. Finally, efficacy and safety of new combinations and advances in insulin therapy will be briefly discussed. Expert commentary: The recent data from randomized controlled trials, meta-analyses and observational real-life studies should trigger a revision of the algorithm for the treatment of hyperglycemia in type 2 diabetes, especially in patients with high cardiovascular and/or renal risk.
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Affiliation(s)
- André J Scheen
- a Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine , CHU Liège , Liège , Belgium.,b Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM) , University of Liège , Liège , Belgium
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14
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Welters A, Klüppel C, Mrugala J, Wörmeyer L, Meissner T, Mayatepek E, Heiss C, Eberhard D, Lammert E. NMDAR antagonists for the treatment of diabetes mellitus-Current status and future directions. Diabetes Obes Metab 2017; 19 Suppl 1:95-106. [PMID: 28880473 DOI: 10.1111/dom.13017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/18/2017] [Accepted: 05/20/2017] [Indexed: 12/16/2022]
Abstract
Diabetes mellitus is characterized by chronically elevated blood glucose levels accelerated by a progressive decline of insulin-producing β-cells in the pancreatic islets. Although medications are available to transiently adjust blood glucose to normal levels, the effects of current drugs are limited when it comes to preservation of a critical mass of functional β-cells to sustainably maintain normoglycemia. In this review, we recapitulate recent evidence on the role of pancreatic N-methyl-D-aspartate receptors (NMDARs) in β-cell physiology, and summarize effects of morphinan-based NMDAR antagonists that are beneficial for insulin secretion, glucose tolerance and islet cell survival. We further discuss NMDAR-mediated molecular pathways relevant for neuronal cell survival, which may also be important for the preservation of β-cell function and mass. Finally, we summarize the literature for evidence on the role of NMDARs in the development of diabetic long-term complications, and highlight beneficial pharmacologic aspects of NMDAR antagonists in diabetic nephropathy, retinopathy as well as neuropathy.
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Affiliation(s)
- Alena Welters
- Institute of Metabolic Physiology, Department of Biology, Heinrich Heine University, Düsseldorf, Germany
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Carina Klüppel
- Institute of Metabolic Physiology, Department of Biology, Heinrich Heine University, Düsseldorf, Germany
| | - Jessica Mrugala
- Institute for Beta Cell Biology, German Diabetes Center, Leibniz Center for Diabetes Research, Düsseldorf, Germany
- German Center for Diabetes Research, Helmholtz Zentrum München, Neuherberg, Düsseldorf, Germany
| | - Laura Wörmeyer
- Institute of Metabolic Physiology, Department of Biology, Heinrich Heine University, Düsseldorf, Germany
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Ertan Mayatepek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Christian Heiss
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Daniel Eberhard
- Institute of Metabolic Physiology, Department of Biology, Heinrich Heine University, Düsseldorf, Germany
| | - Eckhard Lammert
- Institute of Metabolic Physiology, Department of Biology, Heinrich Heine University, Düsseldorf, Germany
- Institute for Beta Cell Biology, German Diabetes Center, Leibniz Center for Diabetes Research, Düsseldorf, Germany
- German Center for Diabetes Research, Helmholtz Zentrum München, Neuherberg, Düsseldorf, Germany
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Rick JT, Caveney E. Response to the 'Comment on the editorial by Turner et al. on Assessment of cardiovascular risk of new drugs for the treatment of diabetes mellitus: risk assessment vs. risk aversion by Zannad et al.'. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2017; 3:130. [PMID: 28444393 DOI: 10.1093/ehjcvp/pvx011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Indexed: 06/07/2023]
Affiliation(s)
- J Turner Rick
- Cardiac Safety Services, QuintilesIMS, 4820 Emperor Boulevard, Durham, NC 27703, USA
| | - Erica Caveney
- Diabetes Center of Excellence, QuintilesIMS, 4820 Emperor Boulevard, Durham, NC 27703, USA
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Alehagen U, Johansson P, Aaseth J, Alexander J, Brismar K. Increase in insulin-like growth factor 1 (IGF-1) and insulin-like growth factor binding protein 1 after supplementation with selenium and coenzyme Q10. A prospective randomized double-blind placebo-controlled trial among elderly Swedish citizens. PLoS One 2017; 12:e0178614. [PMID: 28609475 PMCID: PMC5469470 DOI: 10.1371/journal.pone.0178614] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 05/14/2017] [Indexed: 12/11/2022] Open
Abstract
Background Insulin-like growth factor-1(IGF-1) has a multitude of effects besides cell growth and metabolism. Reports also indicate anti-inflammatory and antioxidative effects. The concentrations of IGF-1 decrease with age and during inflammation. As selenium and coenzyme Q10 are involved in both the antioxidative defense and the inflammatory response, the present study aimed to examine the effects of supplementation with selenium and coenzyme Q10 on concentrations of IGF-1 and its binding protein IGFBP-1 in a population showing reduced cardiovascular mortality following such supplementation. Methods 215 elderly individuals were included and given the intervention for four years. A clinical examination was performed and blood samples were taken at the start and after 48 months. Evaluations of IGF-1, the age adjusted IGF-1 SD score and IGFBP-1 were performed using group mean values, and repeated measures of variance. Findings After supplementation with selenium and coenzyme Q10, applying group mean evaluations, significantly higher IGF-1 and IGF-1 SD scores could be seen in the active treatment group, whereas a decrease in concentration could be seen of the same biomarkers in the placebo group. Applying the repeated measures of variance evaluations, the same significant increase in concentrations of IGF-1 (F = 68; P>0.0001), IGF-1 SD score (F = 29; P<0.0001) and of IGFBP-1 (F = 6.88; P = 0.009) could be seen, indicating the effect of selenium and coenzyme Q10 also on the expression of IGF-1 as one of the mechanistic effects of the intervention. Conclusion Supplementation with selenium and coenzyme Q10 over four years resulted in increased levels of IGF-1 and the postprandial IGFBP-1, and an increase in the age-corrected IGF-1 SD score, compared with placebo. The effects could be part of the mechanistic explanation behind the surprisingly positive clinical effects on cardiovascular morbidity and mortality reported earlier. However, as the effects of IGF-1 are complex, more research on the result of intervention with selenium and coenzyme Q10 is needed.
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Affiliation(s)
- Urban Alehagen
- Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- * E-mail:
| | - Peter Johansson
- Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden
| | - Jan Aaseth
- Research Department, Innlandet Hospital Trust, Brumunddal, Norway, and Hedmark University of Applied Sciences, Elverum, Norway
| | - Jan Alexander
- Norwegian Institute of Public Health, Oslo, and Norwegian University of Life Sciences (NMBU), Ås, Norway
| | - Kerstin Brismar
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
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Scheen AJ. Cardiovascular outcome studies with incretin-based therapies: Comparison between DPP-4 inhibitors and GLP-1 receptor agonists. Diabetes Res Clin Pract 2017; 127:224-237. [PMID: 28402902 DOI: 10.1016/j.diabres.2017.03.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/13/2017] [Indexed: 12/23/2022]
Abstract
Dipeptidyl peptidase-4 inhibitors (DPP-4is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) represent two distinct classes of incretin-based therapies used for the treatment of type 2 diabetes. Non-inferiority versus placebo was shown in large prospective cardiovascular outcome trials in patients with high cardiovascular risk: SAVOR-TIMI 53 (saxagliptin), EXAMINE (alogliptin), and TECOS (sitagliptin); ELIXA (lixisenatide), LEADER (liraglutide) and SUSTAIN 6 (semaglutide). The promises raised by meta-analyses of phase 2-3 trials with DPP-4is were non confirmed as no cardiovascular protection could be evidenced. However, LEADER showed a significant reduction in major cardiovascular events, myocardial infarction, cardiovascular and all-cause mortality in patients treated by liraglutide compared to placebo. These positive results contrasted with the non-inferiority results with lixisenatide in ELIXA. They were partially confirmed with semaglutide in SUSTAIN 6 despite the absence of reduction in cardiovascular mortality. Hospitalisation for heart failure was not increased except with saxagliptin in SAVOR-TIMI 53. The reasons for different outcomes between trials remain largely unknown as well as the precise underlying mechanisms explaining the cardiovascular protection by liraglutide. The clinical relevance of results with DPP-4is and GLP-1RAs is discussed. Ongoing trials with linagliptin and several once-weekly GLP-1RAs should provide new insights into remaining fundamental questions.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, University of Liège, Liège, Belgium; Clinical Pharmacology Unit, CHU Liège, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
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Turner JR. Integrated cardiovascular safety: multifaceted considerations in drug development and therapeutic use. Expert Opin Drug Saf 2017; 16:481-492. [DOI: 10.1080/14740338.2017.1300252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- J. Rick Turner
- Cardiac Safety Services, QuintilesIMS, Durham, NC, USA
- Department of Pharmacy Practice, Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA
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Abstract
INTRODUCTION Despite type 2 diabetes (T2D) management offers a variety of pharmacological interventions targeting different defects, numerous patients remain with persistent hyperglycaemia responsible for severe complications. Unlike resistant hypertension, treatment resistant T2D is not a classical concept although it is a rather common observation in clinical practice. Areas covered: This article proposes a definition for 'treatment resistant diabetes', analyses the causes of poor glucose control despite standard therapy, briefly considers the alternative approaches to glucose-lowering pharmacotherapy and finally describes how to overcome poor glycaemic control, using innovative oral or injectable combination therapies. Expert opinion: Before considering intensifying the pharmacotherapy of a patient with poorly controlled T2D, it is important to verify treatment adherence, target obesity and consider various non pharmacological improvement quality interventions. If treatment resistant diabetes is defined as not achieving glycated haemoglobin target despite oral triple therapy with a third glucose-lowering agent added to metformin-sulfonylurea dual treatment, the combination of a dipeptidyl peptidase-4 (DPP-4) inhibitor and a sodium glucose cotransporter type 2 (SGLT2) inhibitor may offer new opportunities before considering injectable therapies. Insulin basal therapy (± metformin) may be optimized by the addition of a SGLT2 inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist.
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Affiliation(s)
- André J Scheen
- a Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM) , University of Liège , Liège , Belgium.,b Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine , CHU Liège , Liège , Belgium
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Qiao Q, Johnsson K, Grandy S, Kostev K. Treatment Outcomes and Tolerability Following Initiation of GLP-1 Receptor Agonists Among Type 2 Diabetes Patients in Primary Care Practices in Germany. J Diabetes Sci Technol 2017; 11:272-277. [PMID: 27470665 PMCID: PMC5478013 DOI: 10.1177/1932296816661349] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND The aim was to investigate real-world treatment outcomes and tolerability of GLP-1 receptor agonist (GLP-1RA) therapy in patients with type 2 diabetes in Germany. METHODS Patients from 323 primary care practices who started any GLP-1RA therapy (89 Byetta, 108 Bydureon, 347 Victoza patients) between January 1, 2011, and December 31, 2013 (index date) were analyzed retrospectively (Disease Analyzer database, Germany). Changes from baseline in HbA1c, weight, and hypoglycemia were evaluated in 3 follow-up periods of 0-6, 7-12, and 13-18 months. RESULTS A total of 544 diabetes patients (mean age: 57.9 years; men: 54%) were eligible for the study. Mean (SD) HbA1c (%) decreased from 8.3 (1.4) at baseline to 7.4 (1.2) in 6 months, 7.6 (1.3) in 7-12 months and 7.6 (1.4) in 13-18 months, respectively ( P < .001 for all), while the proportion of patients with HbA1c <7% increased from 15% at baseline to 38%, 36% and 35% in the corresponding periods ( P < .0001 for all). Multivariate-adjusted beta coefficients corresponding to changes in HbA1c (%) from baseline were -.52, -.44, and -.44, respectively, in the follow-up periods for baseline HbA1c (%) ( P < .0001 for all). The prevalence of hypoglycemia at baseline was 0.7%; this did not change significantly after treatment. CONCLUSIONS In clinical practice, GLP-1RA treatment was associated with improved glycemic control without increased hypoglycemia for up to 18 months. The higher the baseline HbA1c, the greater the HbA1c reduction recorded.
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The Landscape of Glucose-Lowering Therapy and Cardiovascular Outcomes: From Barren Land to Metropolis. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9257930. [PMID: 29270438 PMCID: PMC5705897 DOI: 10.1155/2017/9257930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/24/2017] [Accepted: 09/14/2017] [Indexed: 12/11/2022]
Abstract
The choice of glucose-lowering therapy (GLT) has expanded to include 11 different classes in addition to insulin. Since the 2008 Food and Drug Administration guidance for industry and mandate of demonstrating cardiovascular (CV) safety prior to any new drug approval, there were several trials primarily conducted to establish that goal. Some had neutral effects, while there were positively beneficial outcomes with more recent studies. Hospitalization for congestive heart failure has also been a heterogeneous finding among the different classes of GLT, with drug outcomes ranging from risky to beneficial. The current review selectively focuses on the evidence for CV outcomes for each class of GLT and summarizes the existing guidelines with regard to these drugs in heart disease. Moreover, it illustrates the dynamic status in the development of evidence. Finally, the review enables healthcare providers to formulate a plan for hypoglycemic therapy which will optimize CV health, in a patient-centered manner.
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Scheen AJ. Effects of reducing blood pressure on cardiovascular outcomes and mortality in patients with type 2 diabetes: Focus on SGLT2 inhibitors and EMPA-REG OUTCOME. Diabetes Res Clin Pract 2016; 121:204-214. [PMID: 27744129 DOI: 10.1016/j.diabres.2016.09.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 09/08/2016] [Indexed: 12/27/2022]
Abstract
Empagliflozin, a sodium-glucose cotransporter type 2 (SGLT2) inhibitor, has shown a remarkable reduction in cardiovascular and all-cause mortality in patients with type 2 diabetes (T2D) and antecedents of cardiovascular disease in the EMPA-REG OUTCOME trial. This effect has been attributed to a hemodynamic rather than a metabolic effect, partly due to the osmotic/diuretic effect of empagliflozin and to the reduction in arterial blood pressure. The present review will: (1) summarize the results of specific studies having tested the blood pressure lowering effects of SGLT2 inhibitors; (2) describe the results of meta-analyses of trials having evaluated the effects on mortality and cardiovascular outcomes of lowering blood pressure in patients with T2D, with a special focus on baseline and target blood pressures; (3) compare the cardiovascular outcome results in EMPA-REG OUTCOME versus other major trials with antihypertensive agents in patients with T2D; and (4) evaluate post-hoc analyses from EMPA-REG OUTCOME, especially subgroups of patients of special interest regarding the blood pressure lowering hypothesis. Although BP reduction associated to empagliflozin therapy may partly contribute to the benefits reported in EMPA-REG OUTCOME, other mechanisms most probably play a greater role in the overall CV protection and reduction in mortality observed in this trial.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, University of Liège, Liège, Belgium; Clinical Pharmacology Unit, CHU Liège, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
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Abstract
Blood glucose-lowering treatment options generally target insulin action or beta-cell function. In diabetes, expression of the sodium-glucose cotransporter-2 (SGLT2) genes is up-regulated and renal threshold increased, resulting in increased glucose reabsorption from glomerular filtrate, reducing urinary glucose excretion and worsening the hyperglycemic condition. The SGLT2 inhibitors (SGLT2i) are a novel class of anti-diabetic drugs that lower blood glucose levels through the suppression of renal glucose reabsorption thereby promoting renal glucose excretion. The efficacy of SGLT2i is reduced in renal impairment because the ability of glucose-lowering is directly proportional to glomerular filtration rate. On the other hand, ongoing research suggests that SGLT2i may offer potential nephroprotection in diabetes. The SGLT2i have been shown to reduce glomerular hyperfiltration, systemic and intraglomerular pressure and the biochemical progression of chronic kidney disease. Additional mechanisms through which SGLT2i exert nephroprotection may include normalizing blood pressure and uricemia. This review explores this bidirectional relationship of the SGLT2i and the glomerulus. While SGLT2i exhibit reduced efficacy in later stages, they exhibit nephroprotective effects in early stages of renal impairment. Funding: Janssen India (Pharmaceutical division of Johnson & Johnson).
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Evidence for Good Cardiovascular Outcomes among Patients with Type 2 Diabetes, and Promising Treatment for Patients with Type 1 Diabetes. Clin Ther 2016; 38:1274-1278. [PMID: 27234359 DOI: 10.1016/j.clinthera.2016.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 05/02/2016] [Indexed: 12/11/2022]
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