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Bagepally BS, Chaikledkaew U, Gurav YK, Anothaisintawee T, Youngkong S, Chaiyakunapruk N, McEvoy M, Attia J, Thakkinstian A. Glucagon-like peptide 1 agonists for treatment of patients with type 2 diabetes who fail metformin monotherapy: systematic review and meta-analysis of economic evaluation studies. BMJ Open Diabetes Res Care 2020; 8:8/1/e001020. [PMID: 32690574 PMCID: PMC7371226 DOI: 10.1136/bmjdrc-2019-001020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/26/2020] [Accepted: 06/08/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To conduct a systematic review and meta-analysis and to pool the incremental net benefits (INBs) of glucagon-like peptide 1 (GLP1) compared with other therapies in type 2 diabetes mellitus (T2DM) after metformin monotherapy failure. RESEARCH DESIGN AND METHODS The study design is a systematic review and meta-analysis. We searched MEDLINE (via PubMed), Scopus and Tufts Registry for eligible cost-utility studies up to June 2018, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. We conducted a systematic review and pooled the INBs of GLP1s compared with other therapies in T2DM after metformin monotherapy failure. Various monetary units were converted to purchasing power parity, adjusted to 2017 US$. The INBs were calculated and then pooled across studies, stratified by level of country income; a random-effects model was used if heterogeneity was present, and a fixed-effects model if it was absent. Heterogeneity was assessed using Q test and I2 statistic. RESULTS A total of 56 studies were eligible, mainly from high-income countries (HICs). The pooled INBs of GLP1s compared with dipeptidyl peptidase-4 inhibitor (DPP4i) (n=10), sulfonylureas (n=6), thiazolidinedione (TZD) (n=3), and insulin (n=23) from HICs were US$4012.21 (95% CI US$-571.43 to US$8595.84, I2=0%), US$3857.34 (95% CI US$-7293.93 to US$15 008.61, I2=45.9%), US$37 577.74 (95% CI US$-649.02 to US$75 804.50, I2=92.4%) and US$14 062.42 (95% CI US$8168.69 to US$19 956.15, I2=86.4%), respectively. GLP1s were statistically significantly cost-effective compared with insulins, but not compared with DPP4i, sulfonylureas, and TZDs. Among GLP1s, liraglutide was more cost-effective compared with lixisenatide, but not compared with exenatide, with corresponding pooled INBs of US$4555.09 (95% CI US$3992.60 to US$5117.59, I2=0) and US$728.46 (95% CI US$-1436.14 to US$2893.07, I2=0), respectively. CONCLUSION GLP1 agonists are a cost-effective choice compared with insulins, but not compared with DPP4i, sulfonylureas and TZDs. PROSPERO REGISTRATION NUMBER CRD42018105193.
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Affiliation(s)
- Bhavani Shankara Bagepally
- Non-Communicable Diseases, ICMR-National Institute of Epidemiology, Chennai, India
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
| | - Usa Chaikledkaew
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Yogesh Krishnarao Gurav
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Epidemiology Group, ICMR-National Institute of Virology, Pune, India
| | - Thunyarat Anothaisintawee
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Department of Family Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sitaporn Youngkong
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | | | - Mark McEvoy
- Centre for Clinical Epidemiology and Biostatistics, Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, New Lambton, New South Wales, Australia
| | - John Attia
- Centre for Clinical Epidemiology and Biostatistics, Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, New Lambton, New South Wales, Australia
- Division of Medicine, John Hunter Hospital, New Lambton, New South Wales, Australia
| | - Ammarin Thakkinstian
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Abstract
BACKGROUND Since the discovery of insulin, it was the only drug available for the treatment of diabetes until the development of sulfonylureas and biguanides 50 years later. But even with the availability of oral glucose-lowering drugs, insulin supplementation was often needed to achieve good glucose control in type 2 diabetes. Insulin NPH became the basal insulin therapy of choice and adding NPH to metformin and/or sulfonylureas became the standard of care until basal insulin analogs were developed and new glucose-lowering drugs became available. AREAS OF UNCERTAINTY The advantages in cost-benefit of insulin analogs and their combination with new glucose-lowering drugs are still a matter of debate. There is no general agreement on how to avoid inertia by prescribing insulin therapy in type 2 diabetes when really needed, as reflected by the diversity of recommendations in the current clinical practice guidelines. DATA SOURCES When necessary for this review, a systematic search of the evidence was done in PubMed and Cochrane databases. THERAPEUTIC ADVANCES Adding new oral glucose-lowering drugs to insulin such as DPP-4 inhibitors lead to a modest HbA1c reduction without weight gain and no increase in hypoglycemia. When SGLT-2 inhibitors are added instead, there is a slightly higher HbA1c reduction, but with body weight and blood pressure reduction. The downside is the increase in genital tract infections. GLP-1 receptor agonists have become the best alternative when basal insulin fails, particularly using fixed ratio combinations. Rapid-acting insulins via the inhaled route may also become an alternative for insulin supplementation and/or intensification. "Smart insulins" are under investigation and may become available for clinical use in the near future. CONCLUSIONS Aggressive weight loss strategies together with the new glucose-lowering drugs which do not cause hypoglycemia nor weight gain should limit the number of patients with type 2 diabetes needing insulin. Nevertheless, because of therapeutic inertia and the progressive nature of the disease, many need at least a basal insulin supplementation and insulin analogs are the best choice as they become more affordable. Fixed ratio combinations with GLP1 receptor agonists are a good choice for intensification of insulin therapy.
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Pappachan JM, Fernandez CJ, Chacko EC. Diabesity and antidiabetic drugs. Mol Aspects Med 2019; 66:3-12. [PMID: 30391234 DOI: 10.1016/j.mam.2018.10.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/10/2018] [Accepted: 10/30/2018] [Indexed: 02/06/2023]
Abstract
The prevalence of "diabesity" - diabetes related to obesity - has increased tremendously over the past few decades because of the global obesity epidemic. Although bariatric surgery is the best treatment option for patients with diabesity, a majority of patients are managed only with antidiabetic drugs for various reasons. Diabetes control with antidiabetic agents may affect diabesity outcomes positively or negatively because of their effects on body weight and other metabolic parameters. For this reason, rational use of anti-diabetic medications is imperative to optimise long-term management of diabesity. Understanding the molecular mechanisms of antidiabetic drugs and/or drug combinations on diabesity outcomes are therefore important not only for the basic scientists but also for clinicians. This review explores the molecular signalling cascades of antidiabetic medications in the management of diabesity.
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Affiliation(s)
- Joseph M Pappachan
- Department of Endocrinology, Diabetes& Metabolism, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, LE21 9QS, United Kingdom.
| | - Cornelius J Fernandez
- Department of Endocrinology, Diabetes& Metabolism, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, LE21 9QS, United Kingdom
| | - Elias C Chacko
- Department of Endocrinology & Diabetes, Jersey Hospital, Jersey, JE1 4SE, United Kingdom
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Sun D, Zhang X, Hou XX. Effects of Insulin Treatment with Glargine or Premixed Insulin Lispro Programs in Type 2 Diabetes Mellitus Patients: A Meta-analysis of Randomized Clinical Trials. Diabetes Technol Ther 2018; 20:622-627. [PMID: 30095984 DOI: 10.1089/dia.2018.0132] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The purpose of this study was to compare the efficacy and safety of intensive insulin therapy (premixed insulin lispro vs. insulin glargine) in patients with type 2 diabetes mellitus (T2DM). METHODS MEDLINE, EMBASE, the Cochrane Library, and www.clinicaltrials.gov were systematically searched for randomized clinical trials (RCTs) of patients with T2DM treated with either premixed insulin lispro or insulin glargine for a duration of 24 weeks. RESULTS A total of 13 RCTs and 5401 patients were included in this study. In parallel trials and crossover trials, premixed insulin lispro was found to be superior to insulin glargine at reducing glycosylated hemoglobin (HbA1c) (parallel trials: weighted mean difference [WMD] -0.18%; 95% confidence interval [CI] -0.31 to -0.06; P = 0.004; crossover trials: WMD 0.37%; 95% CI -0.51 to -0.23; P < 0.00001). Premixed insulin lispro resulted in more weight gain than insulin glargine (parallel trials: WMD +0.64 kg; 95% CI +0.14 to +1.15; P = 0.01; crossover trials: WMD +0.74 kg; 95% CI +0.19 to +1.29; P = 0.009), and premixed insulin lispro was associated with a higher risk of hypoglycemia than insulin glargine (parallel trials: odds ratio [OR] 1.20; 95% CI 1.06-1.36; P = 0.005; crossover trials: OR 2.24; 95% CI 1.45-3.46; P = 0.0003). CONCLUSIONS Premixed insulin lispro provides a larger reduction in HbA1c and is associated with a significantly higher risk of hypoglycemia and greater weight gain in patients with T2DM. These findings may be helpful in selecting therapy for individual subjects.
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Affiliation(s)
- Di Sun
- 1 Nursing Teaching and Research Department, The First Affiliated Hospital of Liaoning University of Traditional Chinese Medicine , Shenyang, China
| | - Xu Zhang
- 2 School of Nursing, Liaoning University of Traditional Chinese Medicine , Shenyang, China
| | - Xiu-Xin Hou
- 1 Nursing Teaching and Research Department, The First Affiliated Hospital of Liaoning University of Traditional Chinese Medicine , Shenyang, China
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Ko SH, Hur KY, Rhee SY, Kim NH, Moon MK, Park SO, Lee BW, Kim HJ, Choi KM, Kim JH. Antihyperglycemic agent therapy for adult patients with type 2 diabetes mellitus 2017: a position statement of the Korean Diabetes Association. Korean J Intern Med 2017; 32:947-958. [PMID: 29056038 PMCID: PMC5668403 DOI: 10.3904/kjim.2017.298] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 09/15/2017] [Indexed: 12/12/2022] Open
Abstract
In 2017, the Korean Diabetes Association (KDA) published a position statement on the use of antihyperglycemic agents for patients with type 2 diabetes mellitus (T2DM). The KDA regularly updates its Clinical Practice Guidelines, but since the last update in 2015, many results from clinical trials have been introduced, and domestic data from studies performed in Korean patients with T2DM have been published. Recently, evidence from large clinical studies assessing cardiovascular outcomes following the use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists in patients with T2DM were incorporated into the recommendations. Additionally, new data from clinical trials using dipeptidyl peptidase 4 inhibitors and thiazolidinediones in Korean patients with T2DM were added. Following a systematic review and assessment of recent evidence, the KDA updated and modified its clinical practice recommendations regarding the use of antihyperglycemic agents and revised the treatment algorithm for Korean adult patients with T2DM.
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Affiliation(s)
- Seung-Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Youl Rhee
- Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea
| | - Nan-Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Min Kyong Moon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seok-O Park
- Department of Internal Medicine, Gwangmyeong Sungae Hospital, Gwangmyeong, Korea
| | - Byung-Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Jin Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Kyung Mook Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jin Hwa Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chosun University College of Medicine, Gwangju, Korea
| | - Committee of Clinical Practice Guideline of Korean Diabetes Association
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Internal Medicine, Gwangmyeong Sungae Hospital, Gwangmyeong, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chosun University College of Medicine, Gwangju, Korea
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Ko SH, Hur KY, Rhee SY, Kim NH, Moon MK, Park SO, Lee BW, Kim HJ, Choi KM, Kim JH. Antihyperglycemic Agent Therapy for Adult Patients with Type 2 Diabetes Mellitus 2017: A Position Statement of the Korean Diabetes Association. Diabetes Metab J 2017; 41:337-348. [PMID: 29086531 PMCID: PMC5663672 DOI: 10.4093/dmj.2017.41.5.337] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 09/15/2017] [Indexed: 12/15/2022] Open
Abstract
In 2017, the Korean Diabetes Association (KDA) published a position statement on the use of antihyperglycemic agents for patients with type 2 diabetes mellitus (T2DM). The KDA regularly updates its Clinical Practice Guidelines, but since the last update in 2015, many results from clinical trials have been introduced, and domestic data from studies performed in Korean patients with T2DM have been published. Recently, evidence from large clinical studies assessing cardiovascular outcomes following the use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists in patients with T2DM were incorporated into the recommendations. Additionally, new data from clinical trials using dipeptidyl peptidase 4 inhibitors and thiazolidinediones in Korean patients with T2DM were added. Following a systematic review and assessment of recent evidence, the KDA updated and modified its clinical practice recommendations regarding the use of antihyperglycemic agents and revised the treatment algorithm for Korean adult patients with T2DM.
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Affiliation(s)
- Seung Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Youl Rhee
- Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea
| | - Nan Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Min Kyong Moon
- Department of Internal Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Seok O Park
- Department of Internal Medicine, Gwangmyeong Sungae Hospital, Gwangmyeong, Korea
| | - Byung Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Jin Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Kyung Mook Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.
| | - Jin Hwa Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chosun University College of Medicine, Gwangju, Korea
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Busch RS, Kane MP. Combination SGLT2 inhibitor and GLP-1 receptor agonist therapy: a complementary approach to the treatment of type 2 diabetes. Postgrad Med 2017; 129:686-697. [PMID: 28657399 DOI: 10.1080/00325481.2017.1342509] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Among persons with type 2 diabetes (t2d), the development of glucose intolerance involves dysfunction in several organs and tissues, including the muscle, liver, pancreas, kidney, gastrointestinal tract, adipose tissue, and brain. individuals with t2d typically have a number of comorbidities, including hypertension, hyperlipidemia, and being overweight or obese, and are, consequently, at high cardiovascular risk. guidelines recommend a comprehensive care strategy that includes treatment of diabetes-related complications and comorbidities beyond those related to hyperglycemia. use of glucose-lowering therapies with complementary activities that address multiple facets of the disease may improve long-term outcomes for patients with t2d. two recent drug classes developed for use in t2d, glucagon-like peptide-1 receptor agonists (glp-1ras) and sodium glucose cotransporter 2 (sglt2) inhibitors, have been shown in clinical trials to have beneficial effects on glycemic control, body weight, cardiovascular risk factors, and (for liraglutide, semaglutide, and empagliflozin) cardiovascular outcomes, while having an acceptable safety profile. between them, these drug classes directly or indirectly affect many of the organs and tissues involved in the pathogenesis of t2d, and their beneficial effects on glycemic- and cardiovascular-related parameters are likely to be complementary and potentially additive. in the largest clinical trial of a glp-1ra and an sglt2 inhibitor in combination (duration-8), patients with t2d (n = 685) who received exenatide plus dapagliflozin added to their treatment regimen for 28 weeks had significantly greater reductions from baseline in glycated hemoglobin, body weight, and systolic blood pressure compared with patients who received either drug as monotherapy. this review summarizes the complementary aspects of these drug classes and presents the available data among patients receiving dual therapy with a glp-1ra and an sglt2 inhibitor.
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Affiliation(s)
- Robert S Busch
- a Albany Medical Center Division of Community Endocrinology , Albany , NY , USA
| | - Michael P Kane
- b Department of Pharmacy Practice , Albany College of Pharmacy and Health Sciences , Albany , NY , USA
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'Treatment-resistant' type 2 diabetes: Which definition for clinical practice? DIABETES & METABOLISM 2017; 43:295-297. [PMID: 28552491 DOI: 10.1016/j.diabet.2017.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/18/2017] [Indexed: 02/08/2023]
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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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The Role of the Pharmacist in Managing Type 2 Diabetes with Glucagon-Like Peptide-1 Receptor Agonists as Add-On Therapy. Adv Ther 2017; 34:638-657. [PMID: 28210986 DOI: 10.1007/s12325-017-0491-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Indexed: 12/25/2022]
Abstract
The prevalence and associated clinical burden of type 2 diabetes (T2D) is increasing in the USA and other countries. As a consequence, the role of the pharmacist in managing T2D is expanding, and it is becoming increasingly important for pharmacists to have a complete understanding of the disease course and treatment options. Pharmacists have a key role in the use of injectable therapies, including incretin-based treatment with glucagon-like peptide-1 receptor agonists (GLP-1RAs). This article discusses the role of the pharmacist in the management of patients with T2D, particularly with respect to the use of GLP-1RAs to achieve glycemic control. GLP-1RAs are a class of injectable agents used as an adjunct to diet and exercise to improve glycemic control in adults with T2D. GLP-1RAs have been shown to lower glucose levels, slow gastric emptying, enhance satiety, and reduce body weight without increasing the risk of hypoglycemia. GLP-1RAs currently approved in the USA include exenatide twice daily, liraglutide once daily, and albiglutide, dulaglutide, and exenatide once weekly. Pharmacists can work with physicians to help identify patients for whom GLP-1RA therapy is appropriate. In addition, pharmacists can educate patients regarding medication storage, preparation, and injection techniques, glycated hemoglobin (HbA1c) targets, pre- and post-meal blood glucose goals, adverse events and management strategies, and the long-term benefits of reducing HbA1c. As members of the diabetes care team, pharmacists play an important role in improving patient outcomes. FUNDING AstraZeneca.
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11
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Abstract
PURPOSE OF REVIEW The global prevalence of "diabesity"-diabetes related to obesity-is increasing steadily over the past few decades because of the obesity epidemic. Although bariatric surgery is an effective treatment option for patients with diabesity, its limited availability, invasiveness, relatively high costs and the potential for surgical and postsurgical complications restrict its widespread use. Therefore, medical management is the only option for a majority of patients with diabesity. Diabetes control with several anti-diabetic agents, including insulin, causes weight gain with probability of worsening diabesity. Rational use of anti-diabetic medications with weight loss potential in varying combinations may help to address this key issue for long-term management of diabesity. There is no consensus on such an approach from different professional bodies like American Diabetes Association, European Association for Study of Diabetes, or International Diabetes Federation. We attempt to discuss the key issues and realistic targets for diabesity management in this paper. RECENT FINDINGS Rational use of anti-diabetic combinations can mitigate worsening of diabesity to some extent while managing patients. Retrospective studies showed that combination therapy with glucagon-like peptide-1 (GLP-1) receptor agonists and sodium glucose co-transporter 2 (SGLT-2) inhibitors, when administered along with other anti-diabetic medications, offer the best therapeutic benefit in the medical management of diabesity. Different combinations of other anti-diabetic drugs with minimum weight gain potential were also found useful. Because of insufficient evidence based on prospective randomised controlled trials (RCTs), future research should focus on evolving the appropriate rational drug combinations for the medical management of diabesity.
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Affiliation(s)
- Joseph M Pappachan
- Department of Endocrinology and Diabetes, Royal Lancaster Infirmary, University Hospitals of Morecambe NHS Trust, Ashton Road, Lancaster, LA1 4RP, UK.
| | - Ananth K Viswanath
- Department of Endocrinology and Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK
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12
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Tobias DK, Manson JE. The Obesity Paradox in Type 2 Diabetes and Mortality. Am J Lifestyle Med 2016; 12:244-251. [PMID: 30202394 DOI: 10.1177/1559827616650415] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 04/27/2016] [Accepted: 04/27/2016] [Indexed: 12/20/2022] Open
Abstract
The obesity paradox for survival among individuals with type 2 diabetes has been observed in some but not all studies. Conflicting evidence for the role of overweight and obesity in all-cause mortality may largely be a result of differences in study populations, epidemiological methods, and statistical analysis. For example, analyses among populations with long-term prevalent diabetes and the accrual of other chronic health conditions are more likely to observe that the sickest participants have lower body weights, and therefore, relative to normal weight, overweight and even obesity appear advantageous. Other mortality risk factors, such as smoking, also confound the relationship between body weight and survival, but this behavior varies widely in intensity and duration, making it difficult to assess and effectively adjust for in statistical models. Disentangling the potential sources of bias is imperative in understanding the relevance of excess body weight to mortality in diabetes. In this review, we summarize methodological considerations underlying the observed obesity paradox. Based on the available evidence, we conclude that the obesity paradox is likely an artifact of biases, and once these are accounted for, it is evident that compared with normal body weight, excess body weight is associated with a greater mortality risk.
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Affiliation(s)
- Deirdre K Tobias
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital (DKT, JEM), Boston, Massachusetts.,Harvard Medical School (DKT, JEM), Boston, Massachusetts.,Department of Epidemiology, Harvard T. H. Chan School of Public Health (JEM), Boston, Massachusetts
| | - JoAnn E Manson
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital (DKT, JEM), Boston, Massachusetts.,Harvard Medical School (DKT, JEM), Boston, Massachusetts.,Department of Epidemiology, Harvard T. H. Chan School of Public Health (JEM), Boston, Massachusetts
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Tek C. Naltrexone HCI/bupropion HCI for chronic weight management in obese adults: patient selection and perspectives. Patient Prefer Adherence 2016; 10:751-9. [PMID: 27217728 PMCID: PMC4862388 DOI: 10.2147/ppa.s84778] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Naltrexone, an opiate antagonist, and bupropion, a noradrenergic/dopaminergic antidepressant, have many effects on the reward systems of the brain. These medications impact eating behavior, presumably via their impact on food reward. However, only bupropion induces weight loss in obese individuals, while naltrexone does not have any appreciable effect. The combination of 32 mg of naltrexone and 360 mg of bupropion in a sustained-release combination pill form has been recently approved for obesity treatment. Studies have shown that the combination of these two medications is more effective in inducing weight loss, when combined with lifestyle intervention and calorie reduction, than each individual medicine alone. The naltrexone-bupropion combination, when combined with lifestyle intervention and modest calorie reduction, seems to be quite effective for 6-month and 1-year outcomes for clinically significant weight loss (over 5% of total body weight). These medications are not devoid of serious side effects, however, and careful patient selection can reduce dramatic complications and increase positive outcomes. This paper reviews existing weight loss clinical trials with bupropion and the bupropion-naltrexone combination. Additionally, the rationale for the suggested patient selection and clinical strategies for special patient populations are discussed.
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Affiliation(s)
- Cenk Tek
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- Correspondence: Cenk Tek, Room 267c, Department of Psychiatry, Yale University School of Medicine, 34 Park Street, New Haven, CT 06519, USA, Email
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