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Cohen B, Harris YT, Schulman-Rosenbaum R. Sodium-Glucose Cotransporter 2 Inhibitors Should Be Avoided for the Inpatient Management of Hyperglycemia. Endocr Pract 2024; 30:402-408. [PMID: 38081453 DOI: 10.1016/j.eprac.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/25/2023] [Accepted: 11/14/2023] [Indexed: 12/31/2023]
Abstract
OBJECTIVE Hyperglycemia in patients with type 2 diabetes mellitus is frequently encountered in the hospital setting. The recent guidelines for the management of inpatient hyperglycemia have included the use of dipeptidyl peptidase 4 inhibitors as an alternative to standard insulin therapy in select patients. This raises the question of the inpatient use of sodium-glucose cotransporter 2 inhibitors (SGLT2i), which have gained increasing popularity in the outpatient setting because of beneficial cardiovascular and renal outcomes. This article describes the risks associated with the use of SGLT2i for the management of inpatient hyperglycemia. METHODS A literature review was performed using PubMed and Google Scholar for studies assessing the inpatient use of SGLT2i. Search terms included "SGLT2 inhibitors," "euglycemic DKA," "inpatient hyperglycemia," "DPP4 inhibitors," "hypovolemia," and "urinary tract infections." Studies not written in English were excluded. Forty-eight articles were included. RESULTS Review of the literature showed significant safety concerns with the use of SGLT2i for the inpatient management of hyperglycemia. Hospitalized patients treated with SGLT2i were at increased risk of diabetic ketoacidosis, euglycemic diabetic ketoacidosis, hypovolemia, and urinary tract infections. When compared head-to-head, SGLT2i were not more effective for inpatient glycemic control than dipeptidyl peptidase 4 inhibitors and did not reduce insulin requirements when used in combination with insulin. Although SGLT2i can be considered for the treatment of congestive heart failure, they should be started close to or at the time of discharge. CONCLUSION Although SGLT2i are a preferred pharmacotherapy class for the outpatient management of type 2 diabetes mellitus, there are considerable safety concerns when using them in a hospital setting, and avoidance is recommended.
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Affiliation(s)
- Benjamin Cohen
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Division of Endocrinology, Diabetes and Metabolism, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York
| | - Yael Tobi Harris
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Division of Endocrinology, Diabetes and Metabolism, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York
| | - Rifka Schulman-Rosenbaum
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Division of Endocrinology, Diabetes and Metabolism, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, New York.
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Dwibedi C, Ekström O, Brandt J, Adiels M, Franzén S, Abrahamsson B, Rosengren AH. Randomized open-label trial of semaglutide and dapagliflozin in patients with type 2 diabetes of different pathophysiology. Nat Metab 2024; 6:50-60. [PMID: 38177805 PMCID: PMC10822775 DOI: 10.1038/s42255-023-00943-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/08/2023] [Indexed: 01/06/2024]
Abstract
The limited understanding of the heterogeneity in the treatment response to antidiabetic drugs contributes to metabolic deterioration and cardiovascular complications1,2, stressing the need for more personalized treatment1. Although recent attempts have been made to classify diabetes into subgroups, the utility of such stratification in predicting treatment response is unknown3. We enrolled participants with type 2 diabetes (n = 239, 74 women and 165 men) and features of severe insulin-deficient diabetes (SIDD) or severe insulin-resistant diabetes (SIRD). Participants were randomly assigned to treatment with the glucagon-like peptide 1 receptor agonist semaglutide or the sodium-glucose cotransporter 2 inhibitor dapagliflozin for 6 months (open label). The primary endpoint was the change in glycated haemoglobin (HbA1c). Semaglutide induced a larger reduction in HbA1c levels than dapagliflozin (mean difference, 8.2 mmol mol-1; 95% confidence interval, -10.0 to -6.3 mmol mol-1), with a pronounced effect in those with SIDD. No difference in adverse events was observed between participants with SIDD and those with SIRD. Analysis of secondary endpoints showed greater reductions in fasting and postprandial glucose concentrations in response to semaglutide in participants with SIDD than in those with SIRD and a more pronounced effect on postprandial glucose by dapagliflozin in participants with SIDD than in those with SIRD. However, no significant interaction was found between drug assignment and the SIDD or SIRD subgroup. In contrast, continuous measures of body mass index, blood pressure, insulin secretion and insulin resistance were useful in identifying those likely to have the largest improvements in glycaemic control and cardiovascular risk factors by adding semaglutide or dapagliflozin. Thus, systematic evaluation of continuous pathophysiological variables can guide the prediction of the treatment response to these drugs and provide more information than stratified subgroups ( NCT04451837 ).
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Affiliation(s)
- Chinmay Dwibedi
- Department of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Ola Ekström
- Department of Clinical Sciences, Diabetes and Endocrinology, Lund University, Malmö, Sweden
| | - Jasmine Brandt
- Department of Clinical Chemistry and Pharmacology, Skåne University Hospital, Lund, Sweden
- Clinical Studies Sweden, Forum South, Skåne University Hospital, Lund, Sweden
| | - Martin Adiels
- Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Stefan Franzén
- Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- AstraZeneca, Gothenburg, Sweden
| | - Birgitta Abrahamsson
- Department of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Anders H Rosengren
- Department of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
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Joshi S, Jayanth V, Loganathan S, Sambandamurthy VK, Athalye SN. Insulin Tregopil: An Ultra-Fast Oral Recombinant Human Insulin Analog: Preclinical and Clinical Development in Diabetes Mellitus. Drugs 2023; 83:1161-1178. [PMID: 37578592 DOI: 10.1007/s40265-023-01925-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/15/2023]
Abstract
Insulin therapy is indispensable for achieving glycemic control in all patients with type 1 diabetes mellitus and many patients with type 2 diabetes mellitus. Insulin injections are associated with negative connotations in patients owing to administration discomfort and adverse effects such as hypoglycemia and weight gain. Insulin administered orally can overcome these limitations by providing a convenient and effective mode of delivery with a potentially lower risk of hypoglycemia. Oral insulin mimics the physiologic process of insulin secretion, absorption into the portal circulation, and subsequent peripheral delivery, unlike the subcutaneous route that results in peripheral hyperinsulinemia. Insulin tregopil (IN-105), a new generation human recombinant insulin, methoxy (polyethylene glycol) hexanoyl human recombinant insulin, is developed by Biocon as an ultra-fast onset short-acting oral insulin analog. This recombinant oral insulin is a single short-chain amphiphilic oligomer modified with the covalent attachment of methoxy-triethylene-glycol-propionyl moiety at Lys-β29-amino group of the B-chain via an amide linkage. Sodium caprate, an excipient in the insulin tregopil formulation, is a permeation enhancer that increases its absorption through the gastrointestinal tract. Also, meal composition has been shown to non-significantly affect its absorption. Several global randomized, controlled clinical trials have been conducted in type 1 and type 2 diabetes patients towards the clinical development of insulin tregopil. The formulation shows post-prandial glucose control that is more effective than placebo throughout the meal period; however, compared with an active comparator insulin aspart, the post-prandial control is more effective mainly in the early post-meal period. It shows a good safety profile with a lower incidence of clinically significant hypoglycemia. This review covers the overall clinical development of insulin tregopil establishing it as an ultra-fast onset, short-acting oral insulin analog for optimizing post-prandial glucose.
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Affiliation(s)
- Shashank Joshi
- Joshi Clinic and Lilavati Hospital, Mumbai, Maharashtra, India
| | - Vathsala Jayanth
- Biocon Biologics Ltd, Biocon House, Semicon Park, Electronic City Phase 2, Bengaluru, Karnataka, 560100, India
| | - Subramanian Loganathan
- Biocon Biologics Ltd, Biocon House, Semicon Park, Electronic City Phase 2, Bengaluru, Karnataka, 560100, India.
| | | | - Sandeep N Athalye
- Biocon Biologics Ltd, Biocon House, Semicon Park, Electronic City Phase 2, Bengaluru, Karnataka, 560100, India
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Scheen AJ. The current role of SGLT2 inhibitors in type 2 diabetes and beyond: a narrative review. Expert Rev Endocrinol Metab 2023; 18:271-282. [PMID: 37154218 DOI: 10.1080/17446651.2023.2210673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/02/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Sodium-glucose cotransporter 2 inhibitors (SGLT2is, gliflozins), the most recent oral antihyperglycaemic agents, provide a cardiorenal protection, an effect independent of their glucose-lowering potency. AREAS COVERED The antihyperglycaemic potency of SGLT2is was compared with that of dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists, especially when added to metformin monotherapy. Main results of cardiovascular/renal outcome trials with SGLT2is were summarized in different populations: patients with type 2 diabetes mellitus (T2DM) with or without established cardiovascular disease, patients (with or without T2DM) with heart failure (with reduced or preserved left ventricular ejection fraction) and in patients (with or without T2DM) with chronic kidney disease (CKD, including stage 4). Original papers and meta-analyses of these different trials have consistently reported a reduction in hospitalization for heart failure (alone or combined with cardiovascular mortality) and a reduced progression of CKD, with an overall good safety profile. EXPERT OPINION Global use of SGLT2is has increased over time but remains suboptimal despite clinically relevant cardiovascular and renal protection, particularly in patients most likely to benefit. SGLT2is has proven both positive benefit-risk balance and cost-effectiveness in at risk patients. New prospects are expected in other complications, i.e. metabolic-associated fatty liver disease and neurodegenerative disorders.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium
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Geist BK, Brath H, Zisser L, Yu J, Fueger B, Nics L, Patronas EM, Kautzky-Willer A, Hacker M, Rasul S. Excretion of glucose analogue with SGLT2 affinity predicts response effectiveness to sodium glucose transporter 2 inhibitors in patients with type 2 diabetes mellitus. Eur J Nucl Med Mol Imaging 2023; 50:3034-3041. [PMID: 37195445 PMCID: PMC10382381 DOI: 10.1007/s00259-023-06256-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/25/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE Sodium-glucose cotransporter 2 inhibitor (SGLT2i) regulation, developed as treatment for patients with type 2 diabetes, can be imaged with the glucose analogue alpha-methyl-4-deoxy-4-[18F]fluoro-D-glucopyranoside (Me4FDG), a positron emission tomography (PET) tracer with a high affinity for SGLT1 and SGLT2 proteins. With regard to therapy effectiveness, we aimed to investigate whether clinical parameters or Me4FDG excretion could predict response to SGLT2i in patients with type 2 diabetes. METHODS In a longitudinal, prospective study, 19 patients with type 2 diabetes underwent Me4FDG combined PET and magnetic resonance imaging (PET/MRI) scans at baseline and 2 weeks after initiation of therapy with SGLT2i, accompanied by the collection of blood and urine samples. Me4FDG-excretion was determined from the Me4FDG uptake in the bladder. Long-term response was determined by HbA1c level after 3 months; a strong response to the therapy was defined as a reduction of HbA1c by at least 10% from baseline. RESULTS SGLT2i resulted in significantly increased Me4FDG excretion (4.8 vs. 45.0, P < 0.001) and urine glucose (56 vs. 2806 mg/dl, P < 0.001). Baseline urine glucose and baseline Me4FDG excretion correlated both with long-term decline in HbA1c with r = 0.55 (P < 0.05). However, only Me4FDG excretion was a predictor of a strong response to SGLT2i (P = 0.005, OR 1.9). CONCLUSIONS Using Me4FDG-PET, we demonstrated for the first time renal SGLT2-related excretion before and after short-term SGLT2i treatment. In contrary to other clinical parameters, SGLT2-related excretion before treatment was a robust predictor of long-term HbA1c response in patients with type 2 diabetes, suggesting that therapy effectiveness is only dependent of endogenous SGLT2 processes.
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Affiliation(s)
- Barbara Katharina Geist
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Helmut Brath
- Diabetes & Metabolic Outpatient Clinic, Health Centre Vienna South, Vienna, Austria
| | - Lucia Zisser
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Josef Yu
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Barbara Fueger
- Department of Biomedical Imaging and Image-Guided Therapy, Division of General and Pediatric Radiology, Medical University of Vienna, Vienna, Austria
| | - Lukas Nics
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Eva Maria Patronas
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alexandra Kautzky-Willer
- Department of Internal Medicine III, Division of Endocrinology and Metabolism, Gender Medicine Unit, Medical University of Vienna, Vienna, Austria
| | - Marcus Hacker
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Sazan Rasul
- Department of Biomedical Imaging and Image-Guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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Scheen AJ. Clinical pharmacology of antidiabetic drugs: What can be expected of their use? Presse Med 2023; 52:104158. [PMID: 36565754 DOI: 10.1016/j.lpm.2022.104158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
The pharmacotherapy of type 2 diabetes mellitus (T2DM) has markedly evolved in the last two decades. Classical antidiabetic agents (sulphonylureas, metformin, insulin) are now in competition with new glucose-lowering medications. Alpha-glucosidase inhibitors and thiazolidinediones (glitazones) were not able to replace older agents, because of insufficient efficacy and/or poor tolerability/safety. In contrast, incretin-based therapies, both dipeptidyl peptidase-4 inhibitors (DPP-4is or gliptins, oral agents) and glucagon-like peptide-1 receptor agonists (GLP-1RAs, subcutaneous injections) are a major breakthrough in the management of T2DM. Because they are not associated with hypoglycaemia and weight gain, DPP-4is tend to replace sulphonylureas as add-on to metformin while GLP-1RAs tend to replace basal insulin therapy after failure of oral therapies. Furthermore, placebo-controlled cardiovascular outcome trials demonstrated neutrality for DPP-4is, but cardiovascular protection for GLP-1RAs in patients with T2DM at high cardiovascular risk. More recently sodium-glucose cotransporter 2 inhibitors (SGLT2is or gliflozins, oral agents) also showed cardiovascular protection, especially a reduction in hospitalization for heart failure, as well as a renal protection in patients with and without T2DM, at high cardiovascular risk, with established heart failure and/or with chronic kidney disease. Thus, GLP-1RAs and SGLT2is are now considered as preferred drugs in T2DM patients with or at high risk of atherosclerotic cardiovascular disease whereas SGLT2is are more specifically recommended in patients with or at risk of heart failure and renal (albuminuric) disease. The management of T2DM is moving from a glucocentric approach to a broader strategy focusing on all risk factors, including overweight/obesity, and to an organ-disease targeted personalized approach.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium; Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
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Gao L, Cheng Z, Su B, Su X, Song W, Guo Y, Liao L, Chen X, Li J, Tan X, Xu F, Pang S, Wang K, Ye J, Wang Y, Chen L, Sun J, Ji L. Efficacy and safety of janagliflozin as add-on therapy to metformin in Chinese patients with type 2 diabetes inadequately controlled with metformin alone: A multicentre, randomized, double-blind, placebo-controlled, phase 3 trial. Diabetes Obes Metab 2023; 25:785-795. [PMID: 36433709 DOI: 10.1111/dom.14926] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
AIM To evaluate the efficacy and safety of janagliflozin in Chinese patients with type 2 diabetes (T2D) inadequately controlled with metformin monotherapy. MATERIALS AND METHODS This multicentre phase 3 trial included a 24-week, randomized, double-blind, placebo-controlled period, followed by a 28-week extension period. Patients (N = 421) with HbA1c of 7.0% or higher and 10.5% or less were randomized (1:1:1) to receive once-daily placebo, janagliflozin 25 or 50 mg. After the 24-week treatment period, patients on placebo were re-randomized (1:1) to janagliflozin 25 or 50 mg for the additional 28-week treatment, whereas patients on janagliflozin maintained the same therapy. The primary endpoint was the change from baseline in HbA1c to week 24. RESULTS At week 24, the placebo-adjusted least squares mean changes of HbA1c were -0.58% and -0.58% with janagliflozin 25 and 50 mg, respectively (P < .0001 for both). The proportion of patients achieving HbA1c less than 7.0% was higher with janagliflozin 25 and 50 mg compared with placebo (41.8%, 41.7% and 28.0%, respectively). Both janagliflozin doses provided significant reductions in fasting plasma glucose, 2-hour postprandial glucose, body weight and systolic blood pressure, and improvements in high-density lipoprotein cholesterol and insulin sensitivity compared with placebo (P < .05 for all). The trends in improvement of these variables were retained during the 28-week extension period. No severe hypoglycaemia occurred throughout the whole 52-week treatment. CONCLUSIONS Janagliflozin 25 or 50 mg once-daily added to metformin therapy significantly improved glycaemic control, reduced body weight and systolic blood pressure, improved high-density lipoprotein cholesterol and insulin sensitivity, and was generally well-tolerated by Chinese T2D patients who had poor glycaemic control with metformin monotherapy.
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Affiliation(s)
- Leili Gao
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Zhifeng Cheng
- Department of Endocrinology, Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Benli Su
- Department of Endocrinology, The Second Hospital of Dalian Medical University, Dalian, China
| | - Xiuhai Su
- Department of Endocrinology, Cangzhou Hospital of Integrated TCM-WM Hebei, Cangzhou, China
| | - Weihong Song
- Department of Endocrinology, Chenzhou First People's Hospital, Chenzhou, China
| | - Yushan Guo
- Department of Endocrinology, The Affiliated Hospital of Beihua University, Jilin, China
| | - Lin Liao
- Department of Endocrinology, Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Xiaowen Chen
- Department of Endocrinology, Huangshi Central Hospital, Huangshi, China
| | - Jiarui Li
- Department of Endocrinology, Cangzhou Central Hospital, Cangzhou, China
| | - Xingrong Tan
- Department of Endocrinology, The Ninth People's Hospital of Chongqing, Chongqing, China
| | - Fangjiang Xu
- Department of Endocrinology, Linyi Central Hospital, Linyi, China
| | - Shuguang Pang
- Department of Endocrinology, Jinan Central Hospital Affiliated to Shandong University, Jinan, China
| | - Kun Wang
- Department of Endocrinology, Nanjing Jiangning Hospital, Nanjing, China
| | - Jun Ye
- Department of Endocrinology, The Second People's Hospital of Hefei, Hefei, China
| | - Yuan Wang
- Department of Endocrinology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lili Chen
- Department of Endocrinology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jingfang Sun
- Jilin Huisheng Bio-pharmaceutical Co., Ltd, Beijing, China
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
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Estimation of marginal structural models under irregular visits and unmeasured confounder: calibrated inverse probability weights. BMC Med Res Methodol 2023; 23:4. [PMID: 36611135 PMCID: PMC9825036 DOI: 10.1186/s12874-022-01831-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 12/26/2022] [Indexed: 01/09/2023] Open
Abstract
Clinical information collected in electronic health records (EHRs) is becoming an essential source to emulate randomized experiments. Since patients do not interact with the healthcare system at random, the longitudinal information in large observational databases must account for irregular visits. Moreover, we need to also account for subject-specific unmeasured confounders which may act as a common cause for treatment assignment mechanism (e.g. glucose-lowering medications) while also influencing the outcome (e.g. Hemoglobin A1c). We used the calibration of longitudinal weights to improve the finite sample properties and to account for subject-specific unmeasured confounders. A Monte Carlo simulation study is conducted to evaluate the performance of calibrated inverse probability estimators using time-dependent treatment assignment and irregular visits with subject-specific unmeasured confounders. The simulation study showed that the longitudinal weights with calibrated restrictions improved the finite sample bias when compared to the stabilized weights. The application of the calibrated weights is demonstrated using the exposure of glucose lowering medications and the longitudinal outcome of Hemoglobin A1c. Our results support the effectiveness of glucose lowering medications in reducing Hemoglobin A1c among type II diabetes patients with elevated glycemic index ([Formula: see text]) using stabilized and calibrated weights.
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Beaubien-Souligny W, Leclerc S, Verdin N, Ramzanali R, Fox DE. Bridging Gaps in Diabetic Nephropathy Care: A Narrative Review Guided by the Lived Experiences of Patient Partners. Can J Kidney Health Dis 2022; 9:20543581221127940. [PMID: 36246342 PMCID: PMC9558862 DOI: 10.1177/20543581221127940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/08/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE OF REVIEW Diabetes affects almost a 10th of the Canadian population, and diabetic nephropathy is one of its main complications. It remains a leading cause of kidney failure despite the availability of effective treatments. SOURCES OF INFORMATION The sources of information are iterative discussions between health care professionals and patient partners and literature collected through the search of multiple databases. METHODS Major pitfalls related to optimal diabetic nephropathy care were identified through discussions between patient partners and clinician researchers. We identified underlying factors that were common between pitfalls. We then conducted a narrative review of strategies to overcome them, with a focus on Canadian initiatives. KEY FINDINGS We identified 5 pitfalls along the diabetic nephropathy trajectory, including a delay in diabetes diagnosis, suboptimal glycemic control, delay in the detection of kidney involvement, suboptimal kidney protection, and deficient management of advanced chronic kidney disease. Several innovative care models and approaches have been proposed to address these pitfalls; however, they are not consistently applied. To improve diabetic nephropathy care in Canada, we recommend focusing initiatives on improving awareness of diabetic nephropathy, improving access to timely evidence-based care, fostering inclusive patient-centered care environment, and generating new evidence that supports complex disease management. It is imperative that patients and their families are included at the center of these initiatives. LIMITATIONS This review was limited to research published in peer-reviewed journals. We did not perform a systematic review of the literature; we included articles that were relevant to the major pitfalls identified by our patient partners. Study quality was also not formally assessed. The combination of these factors limits the scope of our conclusions.
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Affiliation(s)
- William Beaubien-Souligny
- Division of Nephrology, Centre
Hospitalier de l’Université de Montréal, QC, Canada,Department of Medicine, University of
Montreal, QC, Canada
| | - Simon Leclerc
- Division of Nephrology, Department of
Medicine, The Research Institute of the McGill University Health Centre, Montreal,
QC, Canada,Division of Nephrology, Hôpital
Maisonneuve-Rosemont, Montreal, QC, Canada
| | - Nancy Verdin
- The Kidney Foundation of Canada,
London, ON, Canada
| | - Rizwana Ramzanali
- Patient and Community Engagement
Research Program, University of Calgary, AB, Canada
| | - Danielle E. Fox
- Department of Community Health
Sciences, University of Calgary, AB, Canada,Danielle E. Fox, Department of Community
Health Sciences, University of Calgary, TRW 3D44A, 3280 Hospital Drive
Northwest, Calgary, AB T2N 4Z6, Canada.
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10
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Shubrook JH, Radin M, Ali SN, Chubb B, DiPietrantonio K, Collings H, Wyn R, Smith M. Preference for Type 2 Diabetes Therapies in the United States: A Discrete Choice Experiment. Adv Ther 2022; 39:4114-4130. [PMID: 35797004 PMCID: PMC9402769 DOI: 10.1007/s12325-022-02181-7] [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] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/05/2022] [Indexed: 12/01/2022]
Abstract
Introduction Type 2 diabetes mellitus (T2DM) is a chronic condition associated with substantial clinical and economic burden. As multiple therapeutic options are available, patient preferences on treatment characteristics are key in T2DM therapeutic decision-making. This study aimed to determine the preferences of US patients with T2DM for therapies recommended for first pharmacologic intensification after metformin. Methods As part of a discrete choice experiment, an online survey was designed using literature review and qualitative interview findings. Eligibility was met by US patients with T2DM who were aged 18 years or older with an HbA1c ≥ 6.5%. Anonymized therapy profiles were created from six antidiabetic therapies including oral and injectable semaglutide, dulaglutide, empagliflozin, sitagliptin, and thiazolidinediones. Results Eligible patients (n = 500) had a mean HbA1c of 7.4%, and a mean BMI of 32.0 kg/m2, the majority of which (72.2%) were injectable-naïve. The treatment characteristic with greatest importance was mode and frequency of administration (35.5%), followed by body weight change (29.2%), cardiovascular event risk (19.1%), hypoglycemic event risk (9.9%), and HbA1c change (6.5%). An oral semaglutide-like profile was preferred by 91.9–70.1% of respondents depending on the comparator agent, and preference was significant in each comparison (p < 0.05); an injectable semaglutide-like profile was preferred by 89.3–55.7% of respondents in each comparison depending on the comparator agent. Conclusion Patients with T2DM in the USA are significantly more likely to prefer oral or injectable semaglutide-like profiles over those of key comparators from the glucagon-like peptide 1 receptor agonist, sodium-glucose cotransporter 2 inhibitor, dipeptidyl peptidase 4 inhibitor, and thiazolidinedione classes. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02181-7.
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Affiliation(s)
- Jay H Shubrook
- Primary Care Department, Touro University California College of Osteopathic Medicine, Vallejo, CA, USA
| | | | - Sarah N Ali
- Novo Nordisk Pharma Ltd., Plainsboro, NJ, USA
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Abstract
PURPOSE OF REVIEW This review offers a critical narrative evaluation of emerging evidence that sodium-glucose co-transporter-2 (SGLT2) inhibitors exert nephroprotective effects in people with type 2 diabetes. RECENT FINDINGS The SGLT2 inhibitor class of glucose-lowering agents has recently shown beneficial effects to reduce the onset and progression of renal complications in people with and without diabetes. Randomised clinical trials and 'real world' observational studies, mostly involving type 2 diabetes patients, have noted that use of an SGLT2 inhibitor can slow the decline in glomerular filtration rate (GFR), reduce the onset of microalbuminuria and slow or reverse the progression of proteinuria. The nephroprotective effects of SGLT2 inhibitors are class effects observed with each of the approved agents in people with a normal or impaired GFR. These effects are also observed in non-diabetic, lean and normotensive individuals suggesting that the mechanisms extend beyond the glucose-lowering, weight-lowering and blood pressure-lowering effects that accompany their glucosuric action in diabetes patients. A key mechanism is tubuloglomerular feedback in which SGLT2 inhibitors cause more sodium to pass along the nephron: the sodium is sensed by macula cells which act via adenosine to constrict afferent glomerular arterioles, thereby protecting glomeruli by reducing intraglomerular pressure. Other effects of SGLT2 inhibitors improve tubular oxygenation and metabolism and reduce renal inflammation and fibrosis. SGLT2 inhibitors have not increased the risk of urinary tract infections or the risk of acute kidney injury. However, introduction of an SGLT2 inhibitor in patients with a very low GFR is not encouraged due to an initial dip in GFR, and it is prudent to discontinue therapy if there is an acute renal event, hypovolaemia or hypotension.
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Affiliation(s)
| | - Caroline Day
- Life and Health Sciences, Aston University, Birmingham, B4 7ET, UK
| | - Srikanth Bellary
- Life and Health Sciences, Aston University, Birmingham, B4 7ET, UK
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12
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Barrera-Chimal J, Jaisser F, Anders HJ. The mineralocorticoid receptor in chronic kidney disease. Br J Pharmacol 2021; 179:3152-3164. [PMID: 34786690 DOI: 10.1111/bph.15734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/11/2021] [Accepted: 10/22/2021] [Indexed: 11/27/2022] Open
Abstract
Chronic kidney disease (CKD) is a major public health concern, affecting approximately 10% of the population worldwide. CKD of glomerular or tubular origin leads to the activation of stress mechanisms, including the renin angiotensin aldosterone system and mineralocorticoid receptor (MR) activation. Over the last two decades, blockade of the MR has arisen as a potential therapeutic approach against various forms of kidney disease. In this review, we summarize the experimental studies that have shown a protective effect of MR antagonists (MRAs) in non-diabetic and diabetic CKD animal models. Moreover, we review the main clinical trials that have shown the clinical application of MRAs to reduce albuminuria and, importantly, to slow CKD progression. Recent evidence from the FIDELIO trial showed that the MRA finerenone can reduce hard kidney outcomes when added to the standard of care in CKD associated with type 2 diabetes. Finally, we discuss the effects of MRAs relative to those of SGLT2 inhibitors, as well as the potential benefit of combination therapy to maximize organ protection.
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Affiliation(s)
- Jonatan Barrera-Chimal
- Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Ciudad Universitaria, Mexico City, Mexico.,Laboratorio de Fisiología Cardiovascular y Trasplante Renal, Unidad de Investigación UNAM-INC, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Frederic Jaisser
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France.,Université de Lorraine, INSERM Centre d'Investigations Cliniques-Plurithématique 1433, UMR 1116, CHRU de Nancy, French-Clinical Research Infrastructure Network (F-CRIN) INI-CRCT, Nancy, France
| | - Hans-Joachim Anders
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ziemssenstr. 1, D-80336, München
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Comparative efficacy of empagliflozin versus placebo in the treatment of type 1 diabetes mellitus: a meta-analysis of randomized controlled trials. CURRENT ISSUES IN PHARMACY AND MEDICAL SCIENCES 2021. [DOI: 10.2478/cipms-2021-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The objective of this meta-analysis study was to evaluate the comparative efficacy of empagliflozin (25 mg) with placebo in the treatment and management of type 1 diabetes mellitus. This study is a meta-analysis, so an ethical statement is not required. Different databases and individual journal websites like SCOPUS, Science direct, Cochrane review library etc. were used. The articles were evaluated based on the search and eligibility criteria. A total of five RCTs were incorporated in this meta-analysis. These studies contained a total of 1058 patients, including 526 patients with placebo (or control-treated patients), and 532 patients with empagliflozin (25 mg) treated combination. The mean follow-up time ranged from 7 days to 6 months. Overall, mean reduction in placebo was -0.50% and empa-treated was -0.85%, while the pooled WMD was 3.82 995% CI 1.20 – 5.88, p=0.0001). Regarding urinary glucose excretion, that the pooled WMD was 6.67 (95% CI 4.87-10.14, p=0.001) indicated a significant increase in empa-arm compared to placebo. No heterogeneity was found (I2 – 15.03%). This meta-analysis underlined the therapeutic benefit of empagliflozin as an adjunctive therapy for patients with type 1 diabetes.
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14
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Scheen AJ. Efficacy / safety balance of DPP-4 inhibitors versus SGLT2 inhibitors in elderly patients with type 2 diabetes. DIABETES & METABOLISM 2021; 47:101275. [PMID: 34481962 DOI: 10.1016/j.diabet.2021.101275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 12/14/2022]
Abstract
Dipeptidyl peptidase-4 inhibitors (DPP-4is) and sodium-glucose cotransporter type 2 inhibitors (SGLT2is) offer new options for the oral management of type 2 diabetes mellitus (T2DM), with the advantage in the elderly population to be devoid of a high risk of hypoglycaemia. SGLT2is have also shown benefits regarding cardiovascular (heart failure) and renal protection, including in patients with T2DM aged ≥ 65 years while DPP-4is have only proved cardiovascular and renal safety without superiority compared with placebo. The glucose-lowering efficacy of the two pharmacological classes is almost similar including in older patients with T2DM. However, the tolerance and safety profile may be highly different and overall more favourable with DPP-4is than with SGLT2is. Some adverse events have been reported with SGLT2is which may be more prevalent or severe in older patients than in younger patients. The present comprehensive review focuses on the benefit/risk balance in the elderly population with T2DM by comparing the profile of DPP-4is and SGLT2is regarding the following potential issues: metabolic disorders (hypoglycaemia and diabetic ketoacidosis); cardiac and vascular issues (atheromatous cardiovascular disease, heart failure, volume reduction hypotension, and lower limb amputations); renal endpoints including acute renal injury; risk of infections; digestive disorders; bone and skin adverse events; and cancer risk. Both DPP-4is and SGLT2is have their own advantages and disadvantages. Personalised treatment is recommended based upon the efficacy/safety profile of each drug class and individual patient characteristics that may be markedly different among the heterogeneous population of older individuals with T2DM.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium; Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
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15
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Weng J, Zeng L, Zhang Y, Qu S, Wang X, Li P, Fu L, Ma B, Ye S, Sun J, Lu W, Liu Z, Chen D, Cheng Z, Liu H, Zhang T, Zou J. Henagliflozin as add-on therapy to metformin in patients with type 2 diabetes inadequately controlled with metformin: A multicentre, randomized, double-blind, placebo-controlled, phase 3 trial. Diabetes Obes Metab 2021; 23:1754-1764. [PMID: 33769656 DOI: 10.1111/dom.14389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/01/2021] [Accepted: 03/19/2021] [Indexed: 12/24/2022]
Abstract
AIM To evaluate the efficacy and safety of henagliflozin in patients with type 2 diabetes mellitus (T2DM) inadequately controlled with metformin. MATERIAL AND METHODS This multicentre phase 3 trial included a 24-week randomized, double-blind, placebo-controlled period, followed by a 28-week extension period. Patients with a glycated haemoglobin (HbA1c) level of 7.0% (53 mmol/mol) to 10.5% (91 mmol/mol) were randomized and treated with once-daily placebo (n = 161), henagliflozin 5 mg (n = 162), or henagliflozin 10 mg (n = 160). After 24 weeks, patients on placebo were switched to 5 mg or 10 mg henagliflozin for the additional 28-week treatment, and patients on henagliflozin during 24-week treatment period maintained this initial therapy. The primary endpoint was change in HbA1c from baseline to Week 24. RESULTS At Week 24, the least squares mean HbA1c changes versus placebo from baseline were - 0.76% (-8.3 mmol/mol) and - 0.80% (-8.7 mmol/mol) for henagliflozin 5 and 10 mg, respectively (all P < 0.0001). Compared with the placebo group, both doses of henagliflozin lowered fasting plasma glucose, 2-hour postprandial plasma glucose, body weight and blood pressure, and increased the proportions of patients achieving HbA1c <7.0% (53 mmol/mol) at Week 24. The trends in these improvements were sustained over an additional 28 weeks. Slightly higher proportions of ketosis and presence of urine ketone bodies were observed in patients treated with henagliflozin compared to placebo at Week 24. No diabetic ketoacidosis or episodes of severe hypoglycaemia were reported. CONCLUSIONS Henagliflozin 5 mg or 10 mg as add-on therapy to metformin provided a new therapeutic option for the treatment of T2DM patients who have inadequate glycaemic control with metformin alone, and was generally well tolerated.
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Affiliation(s)
- Jianping Weng
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Longyi Zeng
- Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuwei Zhang
- Huaxi Hospital of Sichuan University, Chengdu, China
| | - Shen Qu
- Shanghai 10th People's Hospital, Shanghai, China
| | | | - Ping Li
- Yuncheng Central Hospital, Taiyuan, China
| | - Liujun Fu
- First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Boqing Ma
- Hebei General Hospital, Shijiazhuang, China
| | - Shandong Ye
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Jiao Sun
- Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Weiping Lu
- First Affiliated Huai'an Hospital of Nanjing Medical University, Huai'an, China
| | - Zhiwen Liu
- Shanghai Xuhui District Central Hospital, Shanghai, China
| | | | - Zhifeng Cheng
- Fourth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Haiyan Liu
- Jiangsu Hengrui Medicine Co., Ltd, Shanghai, China
| | - Tao Zhang
- Jiangsu Hengrui Medicine Co., Ltd, Shanghai, China
| | - Jianjun Zou
- Jiangsu Hengrui Medicine Co., Ltd, Shanghai, China
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16
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Search for a Functional Genetic Variant Mimicking the Effect of SGLT2 Inhibitor Treatment. Genes (Basel) 2021; 12:genes12081174. [PMID: 34440348 PMCID: PMC8391850 DOI: 10.3390/genes12081174] [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] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/21/2021] [Accepted: 07/27/2021] [Indexed: 12/23/2022] Open
Abstract
SGLT2 inhibitors (SGLT2i) block renal glucose reabsorption. Due to the unexpected beneficial observations in type 2 diabetic patients potentially related to increased natriuresis, SGLT2i are also studied for heart failure treatment. This study aimed to identify genetic variants mimicking SGLT2i to further our understanding of the potential underlying biological mechanisms. Using the UK Biobank resource, we identified 264 SNPs located in the SLC5A2 gene or within 25kb of the 5′ and 3′ flanking regions, of which 91 had minor allele frequencies >1%. Twenty-seven SNPs were associated with glycated hemoglobin (HbA1c) after Bonferroni correction in participants without diabetes, while none of the SNPs were associated with sodium excretion. We investigated whether these variants had a directionally consistent effect on sodium excretion, HbA1c levels, and SLC5A2 expression. None of the variants met these criteria. Likewise, we identified no common missense variants, and although four SNPs could be defined as 5′ or 3′ prime untranslated region variants of which rs45612043 was predicted to be deleterious, these SNPs were not annotated to SLC5A2. In conclusion, no genetic variant was found mimicking SGLT2i based on their location near SLC5A2 and their association with sodium excretion or HbA1c and SLC5A2 expression or function.
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Cernea S, Dima L, Correll CU, Manu P. Pharmacological Management of Glucose Dysregulation in Patients Treated with Second-Generation Antipsychotics. Drugs 2021; 80:1763-1781. [PMID: 32930957 DOI: 10.1007/s40265-020-01393-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Fasting hyperglycemia, impaired glucose tolerance, prediabetes, and diabetes are frequently present in patients treated with second-generation antipsychotics (SGAPs) for schizophrenia, bipolar disorder, and other severe mental illnesses. These drugs are known to produce weight gain, which may lead to insulin resistance, glucose intolerance, and metabolic syndrome, which constitute important risk factors for the emergence of diabetes. The aim of this review was to formulate therapeutic guidelines for the management of diabetes in patients treated with SGAPs, based on the association between SGAP-induced weight gain and glucose dysregulation. A systematic search in PubMed from inception to March 2020 for randomized controlled trials (RCTs) of diabetes or prediabetes in patients treated with SGAPs was performed. PubMed was also searched for the most recent clinical practice guidelines of interventions for co-morbid conditions associated with diabetes mellitus (DM) (arterial hypertension and dyslipidemia), lifestyle interventions and switching from high metabolic liability SGAPs to safer SGAPs. The search identified 14 RCTs in patients treated with SGAPs. Drug therapy using metformin as first-line therapy and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) or perhaps sodium-glucose cotransporter-2 (SGLT2) inhibitors as add-on therapy, might be preferred in these patients as well, as they favorably influence glucose metabolism and body mass index, and provide cardio-renal benefits in general to the DM population, although for the SGLT-2 inhibitors there are no RCTs in this specific patient category so far. Metformin is also useful for treatment of prediabetes. Arterial hypertension should be treated with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and statins should be used for correction of dyslipidemia. The outcome of lifestyle-changing interventions has been disappointing. Switching from clozapine, olanzapine, or quetiapine to lower cardiometabolic-risk SGAPs, like aripiprazole, brexpiprazole, cariprazine, lurasidone, or ziprasidone, has been recommended.
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Affiliation(s)
- Simona Cernea
- Faculty of Medicine/Department M4/Internal Medicine IV, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, Târgu Mureș, Romania.,Diabetes, Nutrition and Metabolic Diseases Outpatient Unit, Emergency County Clinical Hospital, Târgu Mureş, Romania
| | - Lorena Dima
- Department of Fundamental Disciplines and Clinical Prevention, Faculty of Medicine, Universitatea Transilvania, Nicolae Balcescu Str 59, Brașov, 500019, Romania.
| | - Christoph U Correll
- Charite Universitaetsmedizin, Department of Child and Adolescent Psychiatry, Berlin, and Campus Virchow-Klinikum, Mittelallee 5A, Berlin, 13353, Germany.,Department of Psychiatry and Molecular Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Department of Psychiatry and Molecular Medicine, Zucker Hillside Hospital, Northwell Health System, Glen Oaks, NY, USA
| | - Peter Manu
- Department of Psychiatry, Hofstra Northwell School of Medicine, Hempstead, NY, USA.,Department of Medicine, Hofstra Northwell School of Medicine, Hempstead, NY, USA.,South Oaks Hospital, Northwell Health System, Amityville, NY, USA
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18
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Sandhu P, Ong JP, Garg V, Altaha M, Bello O, Singal SR, Verma S, Yan AT, Connelly KA. The effects of saxagliptin on cardiac structure and function using cardiac MRI (SCARF). Acta Diabetol 2021; 58:633-641. [PMID: 33483855 DOI: 10.1007/s00592-020-01661-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE A recent large cardiovascular outcome trial in patients with type 2 diabetes (T2DM) demonstrated excess heart failure hospitalization with saxagliptin. We sought to evaluate the impact of saxagliptin on cardiac structure and function using cardiac magnetic resonance imaging (CMR) in patients with T2DM without pre-existing heart failure. METHODS In this prospective study, patients with T2DM without heart failure were prescribed saxagliptin as part of routine guideline-directed management. Clinical assessment, CMR imaging and biomarkers were assessed in a blinded fashion and compared following 6 months of continued treatment. The primary outcome was the change in left ventricular (LV) ejection fraction (LVEF) after 6 months of therapy. Key secondary outcomes included changes in LV and right ventricular (RV) end-diastolic volume, ventricular mass, LV global strain and cardiac biomarkers [N terminal pro B-type natriuretic peptide (NT-proBNP) and high sensitivity C-reactive protein (hsCRP)] over 6 months. RESULTS The cohort (n = 16) had a mean age of 59.9 years with 69% being male. The mean hemoglobin A1c (HbA1c) was 8.3%. Mean baseline LVEF was 57% ± 3.4, with no significant change over 6 months (- 0.2%, 95% CI - 2.5, 2.1, p = 0.86). Detailed CMR analyses that included LV/RV volumes, LV mass, and feature tracking-derived strain showed no significant change (all p > 0.50). NT-proBNP and hsCRP levels did not significantly change (p > 0.20). CONCLUSIONS In this cohort of stable ambulatory patients with T2DM without heart failure, saxagliptin treatment was not associated with adverse ventricular remodeling over 6 months as assessed using CMR and biomarkers.
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Affiliation(s)
- Paul Sandhu
- Division of Cardiology, Queen's University, Kingston, ON, Canada
| | - Jann P Ong
- Division of Cardiology, University of Toronto, Toronto, ON, Canada
| | - Vinay Garg
- Division of Cardiology, University of Toronto, Toronto, ON, Canada
| | - Mustafa Altaha
- Division of Cardiology, University of Toronto, Toronto, ON, Canada
| | - Olubenga Bello
- Division of Cardiology, University of Toronto, Toronto, ON, Canada
| | - Sewa R Singal
- Department of Medicine, Humber River Hospital, Toronto, ON, Canada
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Andrew T Yan
- Division of Cardiology, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 193 Yonge St, Toronto, ON, M5B1M8, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kim A Connelly
- Department of Physiology, University of Toronto, Toronto, ON, Canada.
- Division of Cardiology, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 193 Yonge St, Toronto, ON, M5B1M8, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
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19
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Liu SC, Lee CC, Chuang SM, Sun FJ, Zeng YH. Comparison of efficacy and safety of empagliflozin vs linagliptin added to premixed insulin in patients with uncontrolled type 2 diabetes: A randomized, open-label study. DIABETES & METABOLISM 2021; 47:101184. [DOI: 10.1016/j.diabet.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/05/2020] [Accepted: 08/08/2020] [Indexed: 01/10/2023]
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20
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Goto S, Ishikawa JY, Idei M, Iwabuchi M, Namekawa M, Nomura T. Life-Threatening Complications Related to Delayed Diagnosis of Euglycemic Diabetic Ketoacidosis Associated with Sodium-Glucose Cotransporter-2 Inhibitors: A Report of 2 Cases. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929773. [PMID: 33723205 PMCID: PMC7980085 DOI: 10.12659/ajcr.929773] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Case series Patients: Female, 52-year-old • Female, 76-year-old Final Diagnosis: Euglycemic diabetic ketoacidosis • myocardial infarction • sinus node dysfunction Symptoms: Unconsciousness • vomiting Medication: — Clinical Procedure: Hemodialysis • pacemaker insertion Specialty: Critical Care Medicine • Endocrinology and Metabolic
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Affiliation(s)
- Shunsaku Goto
- Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Jun-Ya Ishikawa
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Masafumi Idei
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Masahiro Iwabuchi
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Motoki Namekawa
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Takeshi Nomura
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
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21
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Cardiovascular effects and mechanisms of sodium-glucose cotransporter-2 inhibitors. Chronic Dis Transl Med 2020; 6:239-245. [PMID: 33336169 PMCID: PMC7729105 DOI: 10.1016/j.cdtm.2020.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Indexed: 02/06/2023] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2 inhibitors) are a new type of drug for the treatment of diabetes, and they have been proven to have a good hypoglycemic effect. Several lines of clinical evidence have shown that SGLT2 inhibitors can significantly reduce the risks of atherosclerosis, hospitalization for heart failure, cardiovascular death, and all-cause mortality and delay the progression of chronic kidney disease. Because of the protective effects of SGLT2 inhibitors on the heart and kidney, they are being studied for the treatment of heart failure and chronic kidney disease in patients without diabetes. Therefore, it is necessary for cardiologists, patients with diabetes, and nephrologists to fully understand this type of drug. In this review, we summarize the following three aspects of SGLT2 inhibitors: the recent clinical evidence of their cardiovascular benefits, their mechanisms of action, and their safety.
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22
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Seecheran N, Ramdeen A, Debideen N, Ali K, Grimaldos K, Grimaldos G, Karan A, Seecheran R, Seecheran V, Persad S, Abdullah H, Peram L, Giddings S, Motilal S, Tello-Montoliu A, Schneider D. The Effect of Empagliflozin on Platelet Function Profiles in Patients with Stable Coronary Artery Disease in Trinidad: The EFFECT Pilot Study. Cardiol Ther 2020; 10:189-199. [PMID: 33306161 PMCID: PMC8126525 DOI: 10.1007/s40119-020-00208-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/25/2020] [Indexed: 12/14/2022] Open
Abstract
Introduction This prospective pharmacodynamic (PD) study aimed to assess the effect of the sodium–glucose cotransporter 2 inhibitor (SGLT2i) empagliflozin on platelet reactivity. Methods Patients with stable coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) (n = 20) who were actively treated with dual antiplatelet therapy (DAPT) of aspirin 81 mg daily and clopidogrel 75 mg daily were recruited. Platelet function was measured with the VerifyNow™ P2Y12 assay (Instrumentation Laboratory, Massachusetts, USA) and assessed before the initiation of and after 10 days of treatment with empagliflozin 25 mg once daily maintenance dose regimen. Results were compared with a paired t test. Results The mean P2Y12 reaction units (PRU) on empagliflozin was significantly less than without empagliflozin at baseline (187.35, 95% confidence interval (CI) 155.38–219.32 vs. 217.25, CI 180.60–253.90; p < 0.030). The mean difference in PRU was 29.90 (95% CI 3.17–56.63). No patients experienced any serious adverse events (SAEs). Conclusions Significantly attenuated platelet reactivity was observed on empagliflozin as compared to without empagliflozin. This dedicated pharmacodynamic study could be clinically pertinent for Trinidadian patients with stable CAD and T2DM on DAPT. Further studies are required to confirm these exploratory findings. (Funded by the University of the West Indies, St. Augustine; EFFECT). Clinical Trial Registration ClinicalTrials.gov number NCT04342819.
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Affiliation(s)
- Naveen Seecheran
- The University of the West Indies, St. Augustine, Trinidad and Tobago.
| | - Arvinash Ramdeen
- North Central Regional Health Authority, Mount Hope, Trinidad and Tobago
| | - Niranjan Debideen
- North Central Regional Health Authority, Mount Hope, Trinidad and Tobago
| | - Kabeer Ali
- North Central Regional Health Authority, Mount Hope, Trinidad and Tobago
| | - Kathryn Grimaldos
- North Central Regional Health Authority, Mount Hope, Trinidad and Tobago
| | | | - Abhinav Karan
- North Central Regional Health Authority, Mount Hope, Trinidad and Tobago
| | - Rajeev Seecheran
- North Central Regional Health Authority, Mount Hope, Trinidad and Tobago
| | - Valmiki Seecheran
- North Central Regional Health Authority, Mount Hope, Trinidad and Tobago
| | - Sangeeta Persad
- North Central Regional Health Authority, Mount Hope, Trinidad and Tobago
| | - Harun Abdullah
- North Central Regional Health Authority, Mount Hope, Trinidad and Tobago
| | - Lakshmipathi Peram
- North Central Regional Health Authority, Mount Hope, Trinidad and Tobago
| | - Stanley Giddings
- The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Shastri Motilal
- The University of the West Indies, St. Augustine, Trinidad and Tobago
| | | | - David Schneider
- Cardiovascular Research Institute of Vermont, Colchester, VT, USA
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23
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Scheen AJ. Sodium-glucose cotransporter type 2 inhibitors for the treatment of type 2 diabetes mellitus. Nat Rev Endocrinol 2020; 16:556-577. [PMID: 32855502 DOI: 10.1038/s41574-020-0392-2] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Abstract
The management of type 2 diabetes mellitus (T2DM) is becoming increasingly complex. Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are the newest antidiabetic agents for T2DM. By targeting the kidney, they have a unique mechanism of action, which results in enhanced glucosuria, osmotic diuresis and natriuresis, thereby improving glucose control with a limited risk of hypoglycaemia and exerting additional positive effects such as weight loss and the lowering of blood pressure. Several outcome studies with canagliflozin, dapagliflozin or empagliflozin reported a statistically significant reduction in major cardiovascular events, hospitalization for heart failure and progression to advanced renal disease in patients with T2DM who have established atherosclerotic cardiovascular disease, several cardiovascular risk factors, albuminuric mild to moderate chronic kidney disease or heart failure. Current guidelines proposed a new paradigm in the management of T2DM, with a preferential place for SGLT2is, after metformin, in patients with atherosclerotic cardiovascular disease, heart failure and progressive kidney disease. Ongoing trials might extend the therapeutic potential of SGLT2is in patients with, but also without, T2DM. This Review provides an update of the current knowledge on SGLT2is, moving from their use as glucose-lowering medications to their new positioning as cardiovascular and renal protective agents.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
- Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
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Scheen AJ. SGLT2 Inhibitors as Add-On Therapy to Metformin for People with Type 2 Diabetes: A Review of Placebo-Controlled Trials in Asian versus Non-Asian Patients. Diabetes Metab Syndr Obes 2020; 13:2765-2779. [PMID: 32821142 PMCID: PMC7417649 DOI: 10.2147/dmso.s193528] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/08/2020] [Indexed: 12/13/2022] Open
Abstract
Metformin remains the first pharmacological choice for treating hyperglycemia in type 2 diabetes (T2DM) in most international guidelines. Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are increasingly used as add-on therapy. T2DM pathophysiology is different in Asian and non-Asian (mainly Caucasian) patients. The aim of this systematic review is to compare the efficacy of SGLT2is vs placebo added to metformin in randomized controlled trials (RCTs: range 12-52 weeks) in Asian versus non-Asian patients with T2DM. The primary endpoint is the reduction in glycated hemoglobin (HbA1c) from baseline and key secondary endpoints are reductions in fasting plasma glucose (FPG), body weight (BW) and systolic blood pressure (SBP). Systematic literature search collected 7 RCTs (3 with 2 doses) in Asian patients (10 analyses, n=1164, iSGLT2: canagliflozin, dapagliflozin, ertugliflozin, ipragliflozin, tofogliflozin)) and 10 RCTs (6 with two doses) in non-Asian patients (16 analyses, n=2482, iSGLT2: canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, ipragliflozin). Baseline values of HbA1c (7.98±0.19 vs 7.89±0.27%), FPG (8.80 ±0.46 vs 9.11±0.49 mmol/l) and SBP (128.4±1.6 vs 130.2±3.1 mmHg) were not significantly different in Asian vs non-Asian patients, but BW was lower in Asian patients (71.6±4.8 vs 88.0±2.5 kg, p<0.001). The placebo-adjusted weighed mean differences (WMD, 95% CI) were similar in Asian versus non-Asian patients regarding the reductions in HbA1c -0.60 (-0.68, -0.53) % versus -0.54 (-0.59, -0.49) % (p=0.568), FPG -1.37 (-1.53, -1.22) mmol/l vs -1.37 (-1.47, -1.27) mmol/l (p=0.627), BW when expressed in percentage of baseline BW -2.23 (-2.55, -1.90) % vs -2.16 (-2.37, -1.96) % (p=0.324), and SBP -4.53 (-5.53, -3.53) mmHg vs -4.06 (-4.83, -3.29) mmHg) (p=0.223). In conclusion, clinical efficacy of SGLT2i, as an add-on treatment to metformin monotherapy in patients with T2DM, is similar in Asian versus non-Asian patients, despite known ethnic differences in phenotype and pathophysiology of T2DM.
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Affiliation(s)
- André J Scheen
- Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège University, Liège, Belgium
- Clinical Pharmacology Unit, CHU Liège, Center for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium
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