Emergency Management of Oral Hypoglycemic Drug Toxicity

Comparison of decision tree with common machine learning models for prediction of biguanide and sulfonylurea poisoning in the United States: an analysis of the National Poison Data System

BACKGROUND

Biguanides and sulfonylurea are two classes of anti-diabetic medications that have commonly been prescribed all around the world. Diagnosis of biguanide and sulfonylurea exposures is based on history taking and physical examination; thus, physicians might misdiagnose these two different clinical settings. We aimed to conduct a study to develop a model based on decision tree analysis to help physicians better diagnose these poisoning cases.

METHODS

The National Poison Data System was used for this six-year retrospective cohort study.The decision tree model, common machine learning models multi layers perceptron, stochastic gradient descent (SGD), Adaboosting classiefier, linear support vector machine and ensembling methods including bagging, voting and stacking methods were used. The confusion matrix, precision, recall, specificity, f1-score, and accuracy were reported to evaluate the model's performance.

RESULTS

Of 6183 participants, 3336 patients (54.0%) were identified as biguanides exposures, and the remaining were those with sulfonylureas exposures. The decision tree model showed that the most important clinical findings defining biguanide and sulfonylurea exposures were hypoglycemia, abdominal pain, acidosis, diaphoresis, tremor, vomiting, diarrhea, age, and reasons for exposure. The specificity, precision, recall, f1-score, and accuracy of all models were greater than 86%, 89%, 88%, and 88%, respectively. The lowest values belong to SGD model. The decision tree model has a sensitivity (recall) of 93.3%, specificity of 92.8%, precision of 93.4%, f1_score of 93.3%, and accuracy of 93.3%.

CONCLUSION

Our results indicated that machine learning methods including decision tree and ensembling methods provide a precise prediction model to diagnose biguanides and sulfonylureas exposure.

Early metformin treatment improves pancreatic function and prevents metabolic dysfunction in early overfeeding male rats at adulthood

NEW FINDINGS

What is the central question of this study? Studies reported the efficacy of metformin as a promising drug for preventing or treating of metabolic diseases. Nutrient stresses during neonatal life increase long-term risk for cardiometabolic diseases. Can early metformin treatment prevent the malprogramming effects of early overfeeding? What is the main finding and its importance? Neonatal metformin treatment prevented early overfeeding-induced metabolic dysfunction in adult rats. Inhibition of early hyperinsulinaemia and adult hyperphagia might be associated with decreased metabolic disease risk in these animals. Therefore, interventions during infant development offer a key area for future research to identify potential strategies to prevent the long-term metabolic diseases. We suggest that metformin is a potential tool for intervention.

ABSTRACT

Given the need for studies investigating the possible long-term effects of metformin use at crucial stages of development, and taking into account the concept of metabolic programming, the present work aimed to evaluate whether early metformin treatment might program rats to resist the development of adult metabolic dysfunctions caused by overnutrition during the neonatal suckling phase. Wistar rats raised in small litters (SLs, three pups per dam) and normal litters (NLs, nine pups per dam) were used as models of early overfeeding and normal feeding, respectively. During the first 12 days of suckling, animals from SL and NL groups received metformin, whereas the controls received saline injections. Food intake and body weight were monitored from weaning until 90 days of age, when biometric and biochemical parameters were assessed. The metformin treatment decreased insulin concentrations in pups from SL groups, and as adults, these animals showed improvements in glucose tolerance, insulin sensitivity, body weight gain, white fat pad stores and food intake. Low-glucose insulinotrophic effects were observed in pancreatic islets from both NL and SL groups. These results indicate that early postnatal treatment with metformin inhibits early overfeeding-induced metabolic dysfunctions in adult rats.

Toxicity of Metformin and Hypoglycemic Therapies

Metformin along with other antidiabetic medications provide benefit to patients in the treatment of type 2 diabetes mellitus, but caution is advised in certain scenarios to avoid toxicity in kidney disease. Renal dosing, monitoring of kidney function, and evaluating the risk of developing serious side effects are warranted with some agents. The available literature with regard to incidence of adverse events and toxicity of hypoglycemic therapies is reviewed.

Metformin's performance in in vitro and in vivo genetic toxicology studies

Metformin is a hypoglycemiant drug prescribed for the treatment and control of the type 2 diabetes mellitus. Recently, the potential efficacy of this antidiabetic drug as an anticancer agent has been demonstrated in various mammalian cancer cells. This report evaluates the mutagenic as well as the recombinogenic potentials of the metformin drug in therapeutically relevant plasma concentrations (12.5 µM, 25.0 µM or 50.0 µM). Since the loss of heterozygosity is a process associated with carcinogenesis, the recombinogenic potential of such a drug was evaluated by the homozygotization assay using a heterozygous diploid strain of Aspergillus nidulans. The homozigotization indices (HI) for the genetic markers from the metformin-treated diploids were not statistically different from the negative control (non-treated diploids). For the first time, this indicated a lack of recombinogenic activity of the antidiabetic drug. The mutagenic potential of the metformin drug was evaluated by the chromosome aberrations and the micronuclei tests in human lymphocytes cultures. The metformin drug did not show any significant increase either in the numerical or in the structural chromosome aberrations and did not affect significantly the mitotic index when compared to the negative control. In the in vitro micronucleus test, the drug did not increase the number of micronuclei or nuclear buds when compared with the negative control. The data in this study suggest that the metformin drug is not a secondary cancer inducer, since it has neither showed recombinogenic nor mutagenic activities when used in pharmacological concentrations.

Molecular Mechanism Underlying the Antidiabetic Effects of a Siddha Polyherbal Preparation in the Liver of Type 2 Diabetic Adult Male Rats

A siddha polyherbal preparation consisting of 5 medicinal plants, namely, Asparagus racemosus, Emblica officinalis, Salacia oblonga, Syzygium aromaticum, and Tinospora cordifolia, in equal ratio, was formulated to examine the molecular mechanism by which it exhibits antidiabetic effects in the liver of high-fat and fructose-induced type 2 diabetic rats. The polyherbal preparation treated type 2 diabetic rats showed an increase in insulin receptor, Akt, and glucose transporter2 mRNA levels compared with diabetic rats. Insulin receptor, insulin receptor substrate-2, Akt, phosphorylated Akt substrate of 160kDaThreonine642, α-Actinin-4, β-arrestin-2, and glucose transporter2 proteins were also markedly decreased in diabetic rats, whereas the polyherbal preparation treatment significantly improved the expression of these proteins more than that of metformin-treated diabetic rats. The expression pattern of insulin signaling molecules analyzed in the present study signifies the therapeutic efficacy of the siddha polyherbal preparation.

Octreotide's role in the management of sulfonylurea-induced hypoglycemia

The objective is to evaluate the evidence regarding octreotide's efficacy as a treatment for sulfonylurea-induced hypoglycemia. A search of PubMed for articles published from 1965 to 2008 using combinations of the terms octreotide, antidote, sulfonylurea, overdose, poisoning, and toxicity was performed. References from identified articles were reviewed for additional sources. Animal studies, case reports, case series, and randomized controlled trials were evaluated. An animal model of sulfonylurea overdose demonstrates that octreotide reduces the number of refractory sulfonylurea-induced hypoglycemic episodes. Published case reports describe the use of octreotide to prevent recurrent hypoglycemia after sulfonylurea overdose. A retrospective case series demonstrates that administration of octreotide decreases the need for supplemental dextrose boluses as well as hypoglycemic events. Two prospective, controlled trials determined that octreotide and supplemental dextrose increase blood glucose concentrations with fewer hypoglycemic events. Based on animal and human data, there is sufficient evidence to recommend the use of octreotide with supplemental dextrose for the treatment of sulfonylurea-induced hypoglycemia.

Avoiding hypoglycaemia while achieving good glycaemic control in type 2 diabetes through optimal use of oral agent therapy

BACKGROUND

Patients with type 2 diabetes appear to be at relatively low risk of severe hypoglycaemia and hypoglycaemia unawareness in the early stages of disease. However, declining endogenous insulin secretory capacity due to beta-cell dysfunction/failure eventually produces vulnerability similar to type 1 diabetes. Severe hypoglycaemia itself is associated with serious morbidity and sometimes mortality, and represents an important barrier to achieving glycaemic goals and thus may reduce the protection from diabetes-related morbidity provided by good glycaemic control. Achieving an optimal balance of good glycaemic control and low risk of hypoglycaemia is key to providing optimum care in individuals with type 2 diabetes. This article discusses the issues related specifically to hypoglycaemia associated with oral agent therapy and how these agents may be best employed to provide an optimal balance between hypoglycaemia and good glycaemic control.

METHODS

Embase and Medline searches from 1998 to 2009 using the search terms DPP-4 inhibitors, metformin, oral agents, sulphonylureas, thiazolidinediones AND hypoglycaemia were conducted to identify relevant articles. The limitations inherent in this retrospective, narrative review of previously published publications chosen at the author's discretion are acknowledged.

FINDINGS

Failure to address even mild hypoglycaemia and glycaemic control early in the course of the disease may compromise the success of treatment in the longer term. Metformin, thiazolidinediones and DPP-4 inhibitors, either as monotherapy or in combination with each other, have a well-characterised low propensity to cause hypoglycaemia compared with other therapies.

CONCLUSIONS

Metformin, thiazolidinediones and DPP-4 inhibitors appear to be the most appropriate oral options for minimising the risk of hypoglycaemia. Early and ongoing attention to hypoglycaemia should form an integral part of any long-term glucose control strategy.

Diabetes-Related Medication-Induced Hypoglycemia

Hypoglycemia is a common adverse event in patients with both type 1 and type 2 diabetes and may be a barrier to patients achieving tight glycemic control. It is diagnosed either biochemically, as a blood glucose value, or clinically based on symptoms caused by an autonomic response to changes in blood glucose. Patients that experience repeated episodes of hypoglycemia lose the counterregulatory response that produces symptoms and results in hypoglycemia unawareness. Medications account for the most frequent cause of hypoglycemia in both the inpatient and outpatient setting. Treatment of hypoglycemia may be accomplished via the oral or parenteral route with 15 to 20 g of carbohydrate. Following treatment of the episode, it is important to evaluate for the cause and, if medication related, adjust the patient’s treatment regimen.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics. Suggestions or comments may be addressed to: Jacyntha Sterling, Drug Information Specialist at Saint Francis Hospital, 6161 S Yale Ave., Tulsa, OK 74136 or e-mail: jasterling@saintfrancis.com .