Semaglutide once a week in adults with overweight or obesity, with or without type 2 diabetes in an east Asian population (STEP 6): a randomised, double-blind, double-dummy, placebo-controlled, phase 3a trial

Meta-analysis of the Effect of Semaglutide on Blood Pressure in Obese Populations

OBJECTIVE

The aim was to systematically evaluate the effect of semaglutide on blood pressure in obese populations using meta-analysis methods.

METHODS

Randomized controlled trials on the effect of semaglutide on blood pressure regulation published from the inception of the databases to October 2024 were searched for in PubMed, Embase, the Cochrane Library, and Web of Science. Stata software was used for statistical analysis of the outcome measures in all included studies. Egger's test was applied to assess the risk of publication bias.

RESULTS

A total of 22 studies involving 15,347 participants were included in this meta-analysis. The results showed that, compared to the control group, the semaglutide group significantly reduced systolic blood pressure (SBP) (mean difference [MD] - 2.90, 95% confidence interval [CI] - 3.70 to - 2.11; P < 0.01) and diastolic blood pressure (DBP) (MD - 0.86, 95% CI - 1.34 to - 0.38; P < 0.01). Further subgroup analysis revealed that, compared to diabetic populations, semaglutide had a more significant reduction in SBP (- 1.87, 95% CI - 2.67 to - 1.06, vs - 5.02, 95% CI - 6.10 to - 3.94) and DBP (- 0.43, 95% CI - 0.89 to 0.02, vs - 1.96, 95% CI - 3.12 to - 0.80) in non-diabetic populations. The higher dose of semaglutide (2.4 mg) was found to significantly lower SBP (MD - 4.31, 95% CI - 5.18 to - 3.44) and DBP (MD - 1.84, 95% CI - 2.70 to - 0.98), although mild heterogeneity was present. Sensitivity analysis showed that the exclusion of any single study did not significantly affect the final results.

CONCLUSION

Current evidence suggests that semaglutide can lower SBP and DBP, and increasing the dosage can enhance the blood pressure-lowering effect.

Efficacy and safety of once-weekly tirzepatide in Japanese participants with type 2 diabetes who have obesity or overweight: Subpopulation analysis of the SURMOUNT-2 trial

AIM

To assess the efficacy and safety of once-weekly tirzepatide in Japanese participants with obesity and type 2 diabetes (T2D).

MATERIALS AND METHODS

This subpopulation analysis of 41 Japanese participants from three clinical trial sites in the SURMOUNT-2 trial evaluated the efficacy and safety of tirzepatide as an adjunct to lifestyle interventions in adults with body mass index ≥27 kg/m2 and a diagnosis of T2D with glycated haemoglobin ≥7% to ≤10%. Coprimary endpoints were mean percent change in body weight and proportion of participants who achieved ≥5% body weight reduction at week 72. Percent change in body weight was compared between tirzepatide and placebo using a mixed model for repeated measures.

RESULTS

The mean percent change (standard error) in body weight from baseline to week 72 was statistically significantly greater for both tirzepatide 10 mg (p = 0.001) and 15 mg (p = 0.013) compared with placebo: -12.4% (1.8%) and -10.2% (1.8%), respectively, compared with -3.5% (1.8%). At week 72, 85.7% and 78.6% of participants in the tirzepatide 10 mg and 15 mg groups, respectively, had a body weight reduction of ≥5%, versus 46.2% of participants receiving placebo. Reductions in glycemic parameters, waist circumference and systolic blood pressure, as well as numerical improvements in the lipid profile, were also observed with tirzepatide. No new safety concerns were identified.

CONCLUSIONS

In Japanese adults with obesity and T2D, once-weekly treatment with tirzepatide (10 or 15 mg) demonstrated significant reductions in body weight compared with placebo, with the safety profile generally consistent with previous studies.

Risk of Hearing Loss in Patients Treated with Exendin-4 Derivatives: A Network Meta-Analysis of Glucagon-like Peptide-1 Receptor Agonists and Sodium-Glucose Cotransporter 2 Inhibitors

Background/Objectives: Emerging evidence suggests an association between glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose co-transporter 2 (SGLT2) inhibitors with altered risk of damage in the inner ear system. However, limited research exists on the relationship between these medications and subsequent irreversible hearing loss. We conducted this network meta-analysis (NMA) to evaluate the comparative risk of hearing loss associated with such medications. Methods: In this NMA, we used a confirmatory approach to specifically focus on particular adverse effects of interest (i.e., incidence of hearing loss here) based on the Cochrane recommendation. A Bayesian-based NMA of randomized controlled trials (RCTs) of GLP-1 receptor agonists or SGLT2 inhibitors was conducted. The primary outcome was the hearing loss events. Results: Our NMA of 29 RCTs with 145,895 participants found that only two exendin-4 derivatives-lixisenatide and high-dose efpeglenatide (i.e., 6 mg/week)-showed increased hearing loss events compared to controls. No other GLP-1 receptor agonists or SGLT2 inhibitors demonstrated significantly elevated hearing loss risk. Lixisenatide ranked highest in risk among all investigated regimens. Conclusions: This comprehensive NMA identifies a significant association between exendin-4 derivatives (lixisenatide and efpeglenatide) and potential ototoxicity. Clinicians should carefully consider this potential ototoxicity when prescribing exendin-4 derivatives, particularly in patients with pre-existing hearing loss risk factors.

The Enteric Neuronal Circuitry: A Key Ignored Player in Nutrient Sensing Along the Gut-Brain Axis

The role of the gut-to-brain axis in the regulation of nutrient sensing has been studied extensively for decades. Research has mainly centered on vagal afferent and efferent neurotransmission along the gastrointestinal tract, followed by the integration of luminal information in the nodose ganglia and transmission to vagal integral sites in the brain. The physiological and cellular mechanisms of nutrient sensing by enterocytes and enteroendocrine cells have been well established; however, the roles of the enteric nervous system (ENS) remain elusive. Recent advances in targeting specific neuronal subpopulations and imaging techniques unravel the plausible roles of the ENS in nutrient sensing. In this review, we highlight physiological, cellular, and molecular insights that direct toward direct and indirect roles of the ENS in luminal nutrient sensing and vagal neurotransmission along the gut-brain axis and discuss functional maladaptations observed during metabolic insults, as observed during obesity and associated comorbidities, including type 2 diabetes.

GLP-1 receptor agonists in obesity treatment: Effects on cardiometabolic variables and cardiovascular disease

Obesity is associated with an increased cardiovascular risk. Drugs with glucagon-like peptide-1 receptor agonist (arGLP-1) action for overweight/obesity, such as liraglutide, semaglutide, and tirzepatide, have shown improvements in weight and body composition, as well as in parameters related to glucose metabolism, hypertension, dyslipidemia (reduction of triglycerides and increase in HDL cholesterol), and metabolic dysfunction-associated steatotic liver disease. Additionally, semaglutide 2.4mg sc has shown a reduction in cardiovascular mortality, non-fatal myocardial infarction or stroke, and symptoms of heart failure, while tirzepatide has demonstrated a reduction in cardiovascular mortality and heart failure symptoms in patients with obesity and heart failure. The availability of these new drugs with arGLP-1 action represents a paradigm shift in the treatment of obesity, as they achieve greater weight loss and improvements in cardiometabolic comorbidities.

Glucagon-Like Peptide 1 Receptor Agonists and Mental Health: A Systematic Review and Meta-Analysis

Importance

People with obesity and diabetes have poorer psychiatric and cognitive outcomes and lower quality of life (QOL) compared with those without. Glucagon-like peptide 1 receptor agonists (GLP1-RAs) are treatments for diabetes and obesity that may also influence psychiatric outcomes.

Objective

To conduct a meta-analysis of randomized placebo-controlled trials to evaluate psychiatric, cognitive, and QOL outcomes with GLP1-RA treatment.

Data Sources

MEDLINE, Embase, PsycINFO, and CENTRAL databases were searched from inception through June 24, 2024.

Study Selection

Double-blind placebo-controlled trials comparing GLP1-RA to placebo in adults with overweight/obesity and/or diabetes, reporting on psychiatric, cognition, or QOL outcomes, were included.

Data Extraction and Synthesis

Data extraction was performed in parallel by 2 reviewers. Random-effects meta-analysis was performed. Effect size measures were log risk ratios (log[RR]) and standardized mean differences (Hedges g). The quality of studies was appraised using the Cochrane risk-of-bias tool (RoB2). Certainty of evidence was assessed via GRADEpro.

Main Outcomes and Measures

Main outcomes were risk of psychiatric adverse events (serious and nonserious) and change in mental health symptom severity, health-related quality of life, and cognition.

Results

Eighty randomized clinical trials involving 107 860 patients were included in the meta-analysis. The mean (SD) age of participants across studies in the meta-analysis was 60.1 (7.1) years; 43 251 were female (40.1%) and 64 608 male (59.9%). GLP1-RA treatment was not associated with a significant difference in risk of serious psychiatric adverse events (log[RR] = -0.02; 95% CI, -0.20 to 0.17; P = .87) and nonserious psychiatric adverse events (log[RR] = -0.03; 95% CI, -0.21 to 0.16], P = .76), or depressive symptom change (g = 0.02; 95% CI, -0.51 to 0.55; P = .94), compared with placebo. GLP1-RA treatment was associated with improvements in restrained eating (g = 0.35; 95% CI, 0.13 to 0.57; P = .002) and emotional eating behavior (g = 0.32; 95% CI, 0.11 to 0.54; P = .003) and in mental health-related QOL (g = 0.15; 95% CI, 0.07 to 0.22; P < .001), physical health-related QOL (g = 0.20; 95% CI, 0.14 to 0.26; P < .001), diabetes-related QOL (g = 0.23; 95% CI, 0.15 to 0.32; P < .001), and weight-related QOL (g = 0.27; 95% CI, 0.18 to 0.35; P < .001) compared with placebo.

Conclusions and Relevance

In patients with overweight/obesity and/or diabetes , GLP1-RA treatment is not associated with increased risk of psychiatric adverse events or worsening depressive symptoms relative to placebo and is associated with improvements in QOL, restrained eating, and emotional eating behavior. These findings provide reassurance regarding the psychiatric safety profile of GLP1-RAs and suggest that GLP1-RA treatment contributes to both physical and emotional well-being.

Interplay of Chronic Kidney Disease and the Effects of Tirzepatide in Patients With Heart Failure, Preserved Ejection Fraction, and Obesity: The SUMMIT Trial

BACKGROUND

Obesity leads to both heart failure with a preserved ejection fraction (HFpEF) and to chronic kidney disease (CKD); CKD may both influence the clinical course of obesity-related HFpEF; and incretin-based drugs may influence renal function.

OBJECTIVES

This analysis had dual objectives: 1) to evaluate the influence of CKD on the clinical responses to tirzepatide in patients with obesity-related HFpEF; and 2) to investigate the complexity of tirzepatide-related changes in renal function. For both objectives, we focused on discrepancies between creatinine-based and cystatin C-based estimates of the estimated glomerular filtration rate (eGFR).

METHODS

The SUMMIT trial randomly assigned 731 patients with HFpEF and a body mass index ≥30 kg/m2, who were enriched for participants with CKD. Patients received either placebo or tirzepatide for a median of 104 weeks and were followed for cardiovascular death or worsening heart failure events and for changes in the Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (KCCQ-CSS) after 52 weeks. Because of the confounding produced by obesity and changes in muscle mass, eGFR was assessed at randomization and after 12, 24, and 52 weeks by both creatinine-based and cystatin C-based formulae.

RESULTS

Patients with CKD (based on creatinine or cystatin C) had greater severity of heart failure, as reflected by: 1) worse functional class, KCCQ-CSS scores, and 6-minute walk distance; 2) higher levels of NT-proBNP and cardiac troponin T; and 3) a 2-fold increase in the risk of worsening heart failure events. CKD did not influence the effect of tirzepatide to reduce the relative risk of major adverse heart failure events and to improve KCCQ-CSS, quality of life, and functional capacity, but the absolute risk reduction in the primary events was numerically greater in patients with CKD. Regarding renal function assessments, baseline eGFR-cystatin C was consistently ≈9 mL/min/1.73 m2 lower than that eGFR-creatinine, with significant individual variance. Furthermore, tirzepatide increased eGFR at 52 weeks, assessed by both creatinine-based and cystatin C-based formulae, but with considerable discordance in individual patients. Tirzepatide produced a decline in eGFR at 12 weeks with eGFR-creatinine (but not eGFR-cystatin C), and it led to an improvement in eGFR at 52 weeks in all patients (when assessed by cystatin C), but only in patients with CKD (when assessed by eGFR-creatinine).

CONCLUSIONS

The triad of obesity, HFpEF, and CKD identifies patients with considerable functional impairment and an unfavorable prognosis, who nevertheless respond favorably to tirzepatide. Long-term tirzepatide improves renal function (both by cystatin C and creatinine), but the measurement of eGFR in patients with obesity receiving incretin-based drugs is likely to be skewed by the effects of fat and muscle mass (and by changes in body composition) on the synthesis of both cystatin C and creatinine. (A Study of Tirzepatide [LY3298176] in Participants With Heart Failure With Preserved Ejection Fraction [HFpEF] and Obesity: The SUMMIT Trial; NCT04847557).

Glucagon-like peptide 1 (GLP-1) receptor agonists' use during pregnancy: Safety data from regulatory clinical trials

AIMS

The prevalence of diabetes and obesity continues to rise in women of reproductive age, with significant implications for both mother and foetus. Glucagon-like peptide-1 receptor agonists are effective treatments of diabetes and obesity. However, no Glucagon-like peptide-1 receptor agonists are currently approved for use during pregnancy. We describe the outcomes of unplanned pregnancies during regulatory clinical trials of Glucagon-like peptide-1 receptor agonists submitted to the Food and Drug Administration and European Medicines Agency.

MATERIALS AND METHODS

A search was conducted of the regulatory documentation published by the European Medicines Agency and the Food and Drug Administration on unplanned pregnancies during regulatory clinical trials of Glucagon-like peptide-1 receptor agonists. Clinical and Medical Reviews published by the Center for Drug Evaluation and Research at the Food and Drug Administration for every Glucagon-like peptide-1 receptor agonist prior to market authorisation were assessed to gather information on unplanned pregnancies that occurred while females were partaking in the clinical development programmes of such drugs.

RESULTS

Evidence in women having planned pregnancies is lacking, and the only evidence thus far relies on pregnancies occurring inadvertently during Glucagon-like peptide-1 receptor agonist trials. The incidence of congenital abnormalities in humans appears relatively low following Glucagon-like peptide-1 receptor agonist use during pregnancy.

CONCLUSIONS

Key knowledge gaps must be addressed before the introduction of the Glucagon-like peptide-1 receptor agonist class of drugs for pregnant women. Currently, Glucagon-like peptide-1 receptor agonists should be stopped as soon as the patient becomes aware of a pregnancy. The establishment of patient registries designed to capture data relating to cases of Glucagon-like peptide-1 receptor agonist exposure during pregnancy is a high priority, and where data already exist, the findings need to be published.

GLP-1 receptor agonists, are we witnessing the emergence of a paradigm shift for neuro-cardio-metabolic disorders?

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have emerged as groundbreaking therapeutic agents in managing a spectrum of metabolic disorders, demonstrating remarkable efficacy across multiple organ systems and disease states. These compounds are not only well-established in the treatment of type 2 diabetes (T2D) and obesity-conditions for which they have received widespread approval-but also exhibit promising potential in addressing cardiovascular disease (CVD) and Metabolic dysfunction-associated steatotic liver disease (MASLD). Recent investigations have begun to illuminate the utility of GLP-1RAs in the management of type 1 diabetes (T1D), as well as neurodegenerative disorders such as Alzheimer's and Parkinson's disease and various behavioral disorders. A plethora of clinical trials have consistently validated the capacity of GLP-1RAs to improve glycemic control, promote weight loss, and mitigate cardiovascular risk factors in individuals with T2D and obesity. While their application in T1D remains limited due to safety concerns-particularly regarding the risks of hypoglycemia and hyperglycemic ketoacidosis-emerging data suggest that GLP-1RAs may offer hepatoprotective benefits, potentially reducing liver fat content and decelerating the progression of MASLD. The neuroprotective attributes of GLP-1 RAs have garnered significant interest, with research indicating their potential to alleviate cognitive decline associated with neurodegenerative diseases. Furthermore, preliminary findings highlight the role of GLP-1 RAs in addressing behavioral disorders, emphasizing their extensive therapeutic promise. This comprehensive review synthesizes the current evidence supporting the diverse therapeutic applications of GLP-1RAs, positioning them as "magic drug" therapies for metabolic and neurological disorders. As ongoing research continues to explore innovative applications and combinations of GLP-1RAs, the landscape of disease management in metabolic and neurological contexts is poised for transformative advancements. This review will also critically assess safety considerations and underscore the need for personalized treatment strategies to optimize patient outcomes in these complex and often comorbid conditions.

Semaglutide 2.4 mg in French people living with Class 3 obesity and comorbidities: Baseline characteristics and real-world safety data

AIM

- To describe baseline characteristics and safety data of real-world use of semaglutide 2.4 mg.

METHODS

- Patients with a body mass index (BMI) ≥40 kg/m2 and at least one of the following treated weight-related comorbidities (WRC: hypertension, dyslipidemia, obstructive sleep apnea, cardiovascular disease) were eligible to receive treatment through Temporary Utilization Authorization (TUA: March to June 2022) or Early Access Program (EAP: July 2022 to October 2023). Data were collected according to Health Authorities' requirements. Only descriptive statistics were used.

RESULTS

- Overall, 5,797 (62.8%) treatment requests were sent by sites specialized in obesity management. In total, 478 and 8,568 patients were treated within TUA and EAP cohorts respectively, with mean follow-up durations of 1.2 and 4.5 months, respectively. Mean (SD) BMI was 48.9 (9.7) and 47.0 (7.4) kg/m2, respectively. Age ranged from 18 to 81 years. In the EAP, 57.4%, 26.5%, 12.3% and 3.7% of patients had 1, 2, 3 and 4 WRC. In addition, 15.5% had type 2 diabetes, 18.1% reported depression and 15.4% had osteoarthritis. In the EAP, 247 (2.9%) patients discontinued treatment after a median time of 2.8 months (IQR: 1.2-5.1), mainly due to adverse events (AEs) (47.0%). During TUA, 3 patients discontinued due to AEs. Pancreatitis was reported in 7 cases overall.

CONCLUSION

- The high number of treatment prescriptions in a short period highlights the high unmet medical need. No new safety concerns were identified in this population with severe obesity treated in a real-world setting.

Efficacy and safety of once-weekly semaglutide 2.4 mg for weight management in participants from China: A prespecified analysis of the STEP 7 randomized clinical trial

AIM

To evaluate the efficacy and safety of semaglutide 2.4 mg versus placebo for weight management in a population of Chinese adults with overweight or obesity.

MATERIALS AND METHODS

In STEP 7 (NCT04251156), a double-blind, phase 3a trial, adults from a predominantly East Asian population with overweight or obesity, with or without type 2 diabetes, were randomized 2:1 to once-weekly subcutaneous semaglutide 2.4 mg or placebo for 44 weeks as an adjunct to a reduced-calorie diet and increased physical activity. This prespecified analysis evaluated Chinese participants in STEP 7. The primary endpoints were percentage change in body weight from baseline to Week 44 and the proportion of participants who achieved ≥5% reduction in body weight from baseline.

RESULTS

Overall, 195 Chinese participants were randomized to semaglutide 2.4 mg and 105 to placebo. Estimated change in mean body weight from baseline to Week 44 was -11.8% with semaglutide 2.4 mg versus -3.5% with placebo (estimated treatment difference -8.3%; 95% confidence interval [CI] -10.2, -6.4; p < 0.0001). At Week 44, a greater proportion of participants treated with semaglutide 2.4 mg achieved ≥5% body weight loss versus placebo (85.4% vs. 26.8%): odds ratio 16.1; 95% CI 8.4, 30.9; p < 0.0001. Adverse events were reported by 92.3% of semaglutide-treated participants and 82.9% of placebo-treated participants, the most common of which were gastrointestinal disorders (126/195, 64.6% vs. 35/105, 33.3%).

CONCLUSIONS

These data demonstrate beneficial effects of semaglutide 2.4 mg versus placebo, supporting its use in an adult Chinese population with overweight or obesity.

Efficacy and safety of once-weekly tirzepatide in Japanese patients with obesity disease (SURMOUNT-J): a multicentre, randomised, double-blind, placebo-controlled phase 3 trial

BACKGROUND

Data on tirzepatide in Asian patients with obesity are limited. This study aimed to gain a better understanding of tirzepatide for treatment of Japanese patients with obesity disease (BMI ≥25 kg/m2 with excessive fat accumulation) as defined by the Japanese Society for the Study of Obesity.

METHODS

This was a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial of the efficacy and safety of tirzepatide as an adjunct to lifestyle modifications. Japanese adults with obesity disease (BMI ≥27 kg/m2 accompanied by ≥2 obesity-related health disorders or ≥35 kg/m2 accompanied by ≥1 obesity-related health disorders), excluding diabetes, were assigned 1:1:1 via computer-generated random sequence to receive once weekly subcutaneous tirzepatide (10 mg or 15 mg) or placebo. Coprimary endpoints were the mean percent change in bodyweight and the proportion of participants achieving at least 5% bodyweight reduction at week 72, using the efficacy estimand. Efficacy and safety were assessed in the modified intention-to-treat (mITT) population. This study is registered with ClinicalTrials.gov, NCT04844918.

FINDINGS

Between May 10, 2021, and June 24, 2023, 413 participants were screened, and 267 were randomly assigned. Due to exclusion of one study site, the mITT population was 225 participants (133 [59%] men and 92 [41%] women, mean age 50·8 [SD 10·7] years), with 73 in the tirzepatide 10 mg group, 77 in the tirzepatide 15 mg group, and 75 in the placebo group, of whom 192 (85%) completed both study and treatment. Estimated treatment differences relative to placebo in change in bodyweight at week 72 were -16·1% (95% CI -18·7 to -13·5; p<0·0001) and -21·1% (95% CI -23·6 to -18·5; p<0·0001) following tirzepatide 10 mg and 15 mg, respectively. At week 72, a higher proportion of participants achieved at least 5% bodyweight reduction with tirzepatide 10 mg (67 [94%] of 71) and 15 mg (73 [96%] of 76) compared with placebo (15 [20%] of 75; both p<0·0001). Cardiometabolic and body composition indices were also improved with tirzepatide. Participants treated with tirzepatide experienced treatment-emergent adverse events more frequently (10 mg: n=61 [84%]; 15 mg: n=66 [86%]) than those who received placebo (52 [69%]), most commonly gastrointestinal symptoms. Study discontinuations due to adverse events were infrequent (placebo: n=3 [4%]; tirzepatide 10 mg: n=1 [1%]; tirzepatide 15 mg: n=0).

INTERPRETATION

In Japanese adults with obesity disease, tirzepatide provided clinically a meaningful reduction in bodyweight compared with placebo over 72 weeks, with a safety profile consistent with that observed in global populations.

FUNDING

Eli Lilly and Company.

TRANSLATION

For the Japanese translation of the abstract see Supplementary Materials section.

The Efficacy and Safety of GLP-1 RAs in the Modification of Cardiovascular Morbidity in Patients with Obesity Without Diabetes Mellitus: A Systematic Review and Meta-analysis of Randomized Controlled Trials Involving 32,884 Patients

BACKGROUND

Although the cardioprotective effects of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are well documented in patients with diabetes mellitus, their impact on cardiovascular outcomes in patients with obesity without diabetes remains under debate. Therefore, we conducted this systematic review and meta-analysis of randomized controlled trials (RCTs) to investigate the effects of GLP-1 RAs on cardiovascular outcomes in patients with obesity without diabetes.

METHODS

We systematically searched PubMed, Web of Science, SCOPUS, and Cochrane databases through December 26, 2023. We pooled dichotomous data using risk ratios (RRs) and continuous data using mean differences with 95% confidence intervals (CIs). We evaluated the quality of each study using the Cochrane RoB2 method, and the study protocol was registered on PROSPERO ID: CRD42024498538.

RESULTS

We included 19 RCTs with a total of 32,884 patients. Of these, 15 had a low overall risk of bias, two raised concerns, and two had a high risk of bias. There was no difference between GLP-1 RAs and placebo regarding cardiovascular mortality (RR 0.85; 95% CI 0.71-1.01; p = 0.07). However, compared with placebo, GLP-1 RAs significantly decreased the incidence of all-cause mortality (RR 0.82; 95% CI 0.72-0.93; p < 0.0001), non-cardiovascular mortality (RR 0.77; 95% CI 0.63-0.95; p = 0.01), and myocardial infarction (RR 0.73; 95% CI 0.62-0.86; p < 0.0001). Additionally, patients receiving GLP-1 RAs experienced significant overall weight loss (- 8.53 kg; 95% CI - 12.38 to - 4.68; p < 0.0001) and improvements in lipid profiles, including lower levels of total cholesterol (- 0.77 %; 95% CI - 1.03 to - 0.50; p < 0.0001), triglycerides (- 6.78 %; 95% CI - 8.11 to - 5.46; p < 0.0001), low-density lipoproteins (- 2.85 %; 95% CI - 3.74 to - 1.96; p < 0.0001), and very low-density lipoproteins (- 4.47 %; 95% CI - 5.56 to - 3.38; p < 0.0001). GLP-1 RAs also significantly increased the incidence of any adverse events (RR 1.11; 95% CI 1.05-1.16; p < 0.0001), with no difference regarding the incidence of serious adverse events. However, gastrointestinal adverse events were significantly more frequent in patients receiving GLP-1 RAs, with a higher risk of any gastrointestinal adverse events (RR 2.83; 95% CI 1.86-4.3; p < 0.001), nausea (RR 2.70; 95% CI 2.18-3.33; p < 0.001), diarrhea (RR 1.97; 95% CI 1.68-2.31; p < 0.001), vomiting (RR 3.85; 95% CI 3.32-4.48; p < 0.001), and constipation (RR 2.35; 95% CI 1.94-2.85; p < 0.001) than in those receiving placebo.

CONCLUSION

In obese patients without diabetes, GLP-1 RAs demonstrated substantial benefits in reducing cardiovascular risks, including all-cause mortality and myocardial infarction, and effectively promoted weight loss and improved lipid profiles and blood pressure control. However, their use is accompanied by a higher incidence of gastrointestinal adverse effects and heterogeneity in outcomes, highlighting the need for individualized treatment approaches.

REGISTRATION

PROSPERO identifier number: CRD42024498538.

The pharmacodynamics-based prophylactic benefits of GLP-1 receptor agonists and SGLT2 inhibitors on neurodegenerative diseases: evidence from a network meta-analysis

BACKGROUND

Glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 (SGLT2) inhibitors represent a new generation of antihyperglycemic agents that operate through mechanisms distinct from conventional diabetes treatments. Beyond their metabolic effects, these medications have demonstrated neuroprotective properties in preclinical studies. While clinical trials have explored their therapeutic potential in established neurodegenerative conditions, their role in disease prevention remains unclear. We conducted a network meta-analysis (NMA) to comprehensively evaluate the prophylactic benefits of these agents across multiple neurodegenerative diseases and identify the most promising preventive strategies.

METHODS

We systematically searched PubMed, Embase, ClinicalKey, Cochrane CENTRAL, ProQuest, ScienceDirect, Web of Science, and ClinicalTrials.gov through October 24th, 2024, for randomized controlled trials (RCTs) of GLP-1 receptor agonists or SGLT2 inhibitors. Our primary outcome was the incidence of seven major neurodegenerative diseases: Parkinson's disease, Alzheimer's disease, Lewy body dementia, multiple sclerosis, amyotrophic lateral sclerosis, frontotemporal dementia, and Huntington's disease. Secondary outcomes included safety profiles assessed through dropout rates. We performed a frequentist-based NMA and evaluated risk of bias with Risk of Bias tool. The main result of the primary outcome in the current study would be re-affirmed via sensitivity test with Bayesian-based NMA.

RESULTS

Our analysis encompassed 22 RCTs involving 138,282 participants (mean age 64.8 years, 36.4% female). Among all investigated medications, only dapagliflozin demonstrated significant prophylactic benefits, specifically in preventing Parkinson's disease (odds ratio = 0.28, 95% confidence intervals = 0.09 to 0.93) compared to controls. Neither GLP-1 receptor agonists nor other SGLT2 inhibitors showed significant preventive effects for any of the investigated neurodegenerative conditions. Drop-out rates were comparable across all treatments.

CONCLUSIONS

This comprehensive NMA reveals a novel and specific prophylactic effect of dapagliflozin against Parkinson's disease, representing a potential breakthrough in preventive neurology. The specificity of dapagliflozin's protective effect to Parkinson's disease might rely on its highly selective inhibition to SGLT2. These findings provide important direction for future research and could inform preventive strategies for populations at risk of Parkinson's disease.

TRIAL REGISTRATION

PROSPERO CRD42021252381.

Semaglutide 2.4 mg long-term clinical outcomes in patients with obesity or overweight: a real-world retrospective cohort study in the United States (SCOPE 12 months)

OBJECTIVES

To evaluate the effectiveness of semaglutide 2.4 mg for weight reduction and improvement in cardiometabolic biomarkers at 52 and 68 weeks in a real-world setting in the United States.

METHODS

This noninterventional, retrospective cohort study used the Komodo Health database and included adults with obesity or overweight with ≥1 weight-related condition who initiated treatment with semaglutide 2.4 mg between June 2021 and August 2022 and remained on treatment for 1 year. A paired t-test was used to assess changes in weight, body mass index (BMI), and cardiometabolic biomarkers (systolic blood pressure [SBP], diastolic blood pressure [DBP], glycated hemoglobin [HbA1c], HDL [high-density lipoprotein] cholesterol, LDL [low-density lipoprotein] cholesterol, and triglycerides) from baseline to 52-week and 68-week follow-up.

RESULTS

Among 4,424 eligible patients, 77% were women and the mean (SD) age was 46.7 (10.0) years and BMI was 36.6 (3.6) kg/m2. Dyslipidemia and hypertension were the most common obesity-related comorbidities at baseline. The mean (%) change in weight from baseline was -15.5 kg (-14.5%; p < 0.001; n = 594) at 52 weeks and -15.9 kg (-14.8%; p < 0.001; n = 391) at 68 weeks. The mean change in BMI from baseline was - 4.8 kg/m2 (n = 1124) at 52 weeks and - 4.9 kg/m2 (n = 700) at 68 weeks. At 52weeks, statistically significant improvements in mean values were observed for SBP (-6.3 mmHg), DBP (-3.1 mmHg), HbA1c (-0.4%), LDL cholesterol (-8.1 mg/dL), and triglycerides (-38.4 mg/dL) (all p < 0.001). Mean change at 52 weeks for HDL cholesterol was 1.0 mg/dL; p = 0.109. Results at 68 weeks were similar.

CONCLUSIONS

In this retrospective cohort study, the real-world effectiveness of semaglutide 2.4 mg was demonstrated by reductions in weight and BMI along with improvements in BP, HbA1c, and lipid panel among patients with obesity or overweight.

Novel pharmacotherapies for weight loss: Understanding the role of incretins to enable weight loss and improved health outcomes

Obesity and type 2 diabetes mellitus (T2D) are widespread diseases that significantly impact cardiovascular and renal morbidity and mortality. In the recent years, intensive research has been performed to assess the role of adipose tissue and body fat distribution in the development of metabolic and non-metabolic complications in individuals with obesity. In addition to lifestyle modifications, glucagon-like peptide-1 receptor agonists (GLP-1-RA) have become a meaningful treatment expansion for the management of both disorders. In addition to improving metabolic control and reducing body weight, treatment with GLP-1-RAs reduces cardiovascular and renal events in individuals with obesity with and without diabetes. These important benefits of GLP-1-RAs have triggered new interest in other enteroendocrine and enteropancreatic peptides for treating obesity and its metabolic and non-metabolic consequences. The first peptide dual-agonist targeting glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptors has been approved for the treatment of T2D and obesity. GIP/GLP-1 dual-agonism appear to provide better metabolic control and greater weight reduction compared with GLP-1-R mono-agonism. Other peptide and non-peptide co-agonists are in clinical development for obesity, T2D, metabolic dysfunction-associated steatotic liver disease (MASLD) and other metabolic disorders. This narrative review aims to summarize the available data on approved and emerging enteroendocrine and enteropancreatic based treatment approaches for obesity and metabolic disorders. In addition to available clinical efficacy measures, side effects, limitations and open challenges will also be addressed.

Exploring Glucagon-Like Peptide-1 Receptor Agonists Usage Among Non-Diabetic Healthcare Providers: A Cross-Sectional Multi-Country Study

Background and Aim

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) were initially developed for type 2 diabetes but have gained widespread use for weight management, including among non-diabetic individuals. This study aimed to estimate the prevalence of GLP-1RA use, describe usage patterns, and explore healthcare providers' (HCPs) perceptions of their efficacy and safety.

Methods

A cross-sectional study was conducted among 657 HCPs from 10 countries using a structured online survey between September and December 2023. Convenience sampling was employed, statistical analyses were performed using STATA 17. Associations between demographic characteristics and perceptions of GLP-1RAs were analyzed using the chi-square test.

Results

Among 657 HCPs, 59.2% were female and 40.8% were male, with a median age of 36.0 years (IQR: 29.0-44.0) and a median BMI of 26.7 (IQR: 23.8-30.7). Among professional groups, nurses accounted for 44.7%, followed by physicians (36.2%) and allied health professionals (18.7%). Semaglutide (45.7%, 95% CI: 41.8%-49.5%) was the most commonly used GLP-1RA, followed by Liraglutide (36.9%, 95% CI: 33.2%-40.8%). Other GLP-1RAs were used less frequently, including Dulaglutide (17.0%, 95% CI: 14.2%-20.1%), Exenatide (14.1%, 95% CI: 11.5%-17.0%), Albiglutide (7.0%, 95% CI: 5.1%-9.2%), and Lixisenatide (8.5%, 95% CI: 6.5%-10.9%. Regarding perceived safety, 68.6% considered GLP-1RAs safe. Safety perceptions were significantly associated with educational level (p = 0.022), with participants holding higher degrees being more likely to perceive GLP-1RAs as unsafe (18.3%) compared to those with a bachelor's degree or lower (10.8%). No associations were found with age (p = 0.487), sex (p = 0.729), or BMI (p = 0.089). Similarly, 73.5% of participants considered GLP-1RAs effective for perceived efficacy. No associations were found with sex (p = 0.663) or BMI (p = 0.446). Older participants (p = 0.011) and those with higher education (p = 0.006) were more likely to perceive GLP-1RAs as ineffective.

Conclusion

This study provides the first prevalence estimate of GLP-1RA use among HCPs and GLP1-Ras users and explores the associations between demographic characteristics and perceptions of safety and efficacy. The findings highlight the self-prescribing practices of these medications for weight management and underscore the need for appropriate monitoring to avoid potential health risks.

Real-world cross-sectional study evaluating patient characteristics, disease burden, and treatment approaches in people with obesity disease in Japan

AIM

To describe clinical characteristics, disease burden, and treatment patterns among people with obesity disease (PwOD) in Japan, using data from the Adelphi Real World Obesity Disease Specific Programme™ (DSP).

METHODS

Secondary data from the Japanese DSP cohort (July to December 2022) were analyzed. PwOD had a BMI ≥25 kg/m2 and ≥1 obesity-related complications (ORCs). Outcomes were summarized for all PwOD or stratified by obesity class (BMI ≥25-<35 or ≥35 kg/m2 [high-degree obesity disease]) and use of anti-obesity medications (AOMs).

RESULTS

The study included 442 PwOD (mean age: 52.8 years; 54.8% males; BMI ≥25-<35 kg/m2: 64.5%; BMI ≥35 kg/m2: 35.5%; AOM users: n = 228; non-AOM users: n = 214). High-degree obesity disease was associated with worsened SF-36v2 scores (Physical Component Summary, Physical Functioning, Bodily Pain, and General Health), greater activity impairment, and reduced work productivity. Common weight management approaches were diet (79.9%) and exercise (51.1%). Common prescription AOMs included traditional herbal medicine (67.5%) and mazindol (21.1%). People with high-degree obesity disease (BMI ≥35 vs. ≥25-<35 kg/m2) used more prescription AOMs (57.3 vs. 48.4%), behavioral therapy (9.6 vs. 1.8%), and weight loss surgery (2.6 vs. 0.4%). The difference in weight reduction between AOM and non-AOM users was modest.

CONCLUSIONS

People with high-degree obesity disease experienced greater disease burden. Diet and exercise are common for weight management, while behavioral therapy is less frequently implemented. These findings highlight the challenges and unmet medical needs in treating obesity in Japan and could inform better treatment strategies in Japan and globally among the Asian population.

The promise of incretin-based pharmacotherapies for metabolic dysfunction-associated fatty liver disease

BACKGROUND

The presence of excess liver fat secondary to metabolic dysregulation represents the end-organ manifestation of a systemic disease that can progress to steatohepatitis, cirrhosis and its feared complications of clinical decompensation and hepatocellular cancer. Since metabolic dysfunction-associated fatty liver disease (MAFLD) is highly prevalent globally, there is a pressing need to augment lifestyle interventions with pharmacotherapies to ameliorate disease burden and reduce adverse liver-related events.

PURPOSE

This review summarises current evidence for the utility of incretin mimetics in the MAFLD/MASH arena.

METHODS

A literature review that encompassed multiple database searches to inform the evidence base for incretin drugs in MAFLD/MASH.

RESULTS

Incretin mimetics demonstrate multifarious benefits across the metabolic diseases spectrum with mounting evidence for their role in remitting steatohepatitis and liver fibrosis. Weight loss and insulin sensitisation contribute, but additional mechanisms may also be engaged. Gastrointestinal adverse effects are common but for most, can be managed while preserving the hepatic and cardiometabolic benefits.

CONCLUSION

The literature reveals benefits from incretin-based therapies for MASH, but data on whether they improve long-term hepatic outcomes are awaited to support their future incorporation into routine clinical care.

Glucagon-Like Peptide-1 Agonist Use in Adults With Congenital Heart Disease: Effect, Safety, and Outcomes

BACKGROUND

Obesity is prevalent among patients with adult congenital heart disease (ACHD) and contributes to adverse cardiovascular outcomes. There is a paucity of data regarding glucagon-like peptide-1 receptor agonists (GLP-1 RA) for weight loss in patients with ACHD.

OBJECTIVES

The purpose of this study was to assess the effect, safety, and outcomes of GLP-1 RA among patients with ACHD.

METHODS

This is a retrospective cohort study of patients with ACHD at Mayo Clinic (January 2013-January 2024) who were prescribed semaglutide or liraglutide. The primary endpoint was weight loss. Secondary endpoints were changes in NYHA functional class, hemoglobin A1c, estimated glomerular filtration rate, and safety endpoints of renal adverse event, hypoglycemia, hospitalization/drug discontinuation due to side effects.

RESULTS

Seventy patients received GLP-1 RA over a mean duration of 21 ± 20 months. Majority (85.7%) had moderate/severe complexity congenital heart disease. Weight loss >5% was achieved in 30 (42.9%) patients. Patients with body mass index ≥35 kg/m2 were more likely to achieve weight loss >5% [66.7% vs 40%, P = 0.027]. Younger age resulted in improved weight loss of 0.17 kg per 1-year age difference (P = 0.014). Hemoglobin A1c lowered by a mean of 0.6% (P = 0.054). There were no significant changes in NYHA functional class or estimated glomerular filtration rate. One-third of patients experienced side effects, mostly from gastrointestinal intolerance (20%); 11.4% discontinued the medication due to side effects.

CONCLUSIONS

GLP-1 RAs are safe and effective for weight loss in patients with ACHD with beneficial effects on glycemic control.

Semaglutide as a GLP-1 Agonist: A Breakthrough in Obesity Treatment

This review addresses the role of semaglutide (SMG), a GLP-1 receptor agonist, in the treatment of obesity and its related comorbidities. Originally developed for type 2 diabetes (DM2), SMG has shown significant efficacy in weight reduction, with superior results compared to other treatments in the same class. Its effects include appetite suppression, increased satiety, and improvements in cardiovascular, renal, and metabolic parameters. Studies such as SUSTAIN, PIONEER, and STEP highlight its superiority compared to other GLP-1 receptor agonists and anti-obesity drugs. The oral formulation showed promising initial results, with higher doses (50 mg) showing weight losses comparable to those of subcutaneous administration. Despite its benefits, there are challenges, such as weight regain after cessation of treatment, gastrointestinal adverse effects, and variability of response. Future studies should explore strategies to mitigate these effects, identify predictive factors of efficacy, and expand therapeutic indications to other conditions related to obesity and insulin resistance. The constant innovation in this class of drugs reinforces the potential of SMG to transform treatment protocols for chronic weight-related diseases.

What is the evidence regarding the safety of new obesity pharmacotherapies

The use of gut-hormone receptors agonists as new therapeutic options for obesity and some of its related comorbidities, such as type 2 diabetes, has resulted in an unprecedented efficacy in the medical management of people living with obesity (PLWO). Appraisal of the safety of these drugs is of utmost importance considering the large number of PLWO, and the potentially long exposure to these pharmacotherapies. In this narrative review we summarize the evidence on the safety of liraglutide, semaglutide, and tirzepatide as derived from randomized clinical trials conducted in adults living with obesity. Additionally, the safety of these drugs is put into perspective with that of other drugs currently approved for the treatment of PLWO. Overall, the available data support a favorable efficacy versus safety balance for gut-hormone hormone receptor analogues in the treatment of these subjects. Nonetheless, it should be acknowledged that in the context of a chronic disease that has reached epidemic proportions, data from randomized clinical trials aimed primarily at proving the efficacy of these drugs may have been insufficient to unveil all the safety issues. Thus, continuous surveillance on the adverse effects of liraglutide, semaglutide, and tirzepatide is required as we use these drugs in a broader population than that represented in currently available clinical trials.

Role of Incretin Mimetics in Cardiovascular Outcomes and Other Classical Cardiovascular Risk Factors beyond Obesity and Diabetes Mellitus in Nondiabetic Adults with Obesity: a Meta-analysis of Randomized Controlled Trials

BACKGROUND

Emerging data on cardiovascular outcomes, specifically major adverse cardiovascular events (MACE), are being reported from various trials involving incretin mimetics, such as glucagon-like peptide-1 receptor agonists (GLP-1 RA) and glucose-dependent insulinotropic polypeptide (GIP), especially among patients with obesity and diabetes. Our aim was to evaluate this matter, while also involving various traditional cardiovascular risk factors [e.g., several body weight (BW) parameters, blood pressure (BP), lipid profile].

METHODS

A search of PubMed, Europe PMC, ScienceDirect, Cochrane, and ClinicalTrials.gov up to September 2024 was performed to identify GLP-1 RA and GIP trials in MACE risk reduction as a primary endpoint. Our secondary endpoints included a reduction in BW, waist circumference (WC), body mass index (BMI), BP changes, and lipid modifying effects, while also yielding safety concerns surrounding the use of these pharmaceutical agents. Mean differences (MD) and risk ratios (RR) were summarized using random-effects model.

RESULTS

A total of 11 eligible randomized controlled trials (RCTs) comprising 8 GLP-1 RA trials and 3 dual GLP-1 RA/GIP (tirzepatide) trials were included. Compared with control groups, GLP-1 RA significantly reduced the MACE risk by 32% [RR 0.68 (95% CI 0.53-0.87); P = 0.002; I2 = 73%, P-heterogeneity < 0.001] and 59% for tirzepatide [RR 0.41 (95% CI 0.18-0.92); P = 0.03; I2 = 0%, P-heterogeneity = 0.96]. Incretin mimetics also substantially reduced BW, BP, and improved lipid panel measures. However, there was an increased risk of adverse events, specifically gastrointestinal disorders within the incretin mimetics subset.

CONCLUSIONS

Incretin mimetics have shown promise in reducing MACE risk while also enhancing cardiovascular risk factors, including blood pressure and lipid profile, in adults with obesity without diabetes.

Effect of once-weekly subcutaneous semaglutide on abdominal visceral fat area in Japanese adults with overweight and obesity: A post hoc analysis of the STEP 6 trial

OBJECTIVE

A post hoc analysis of a subset of participants with visceral fat area (VFA) measurements in the STEP 6 trial was conducted to examine both the correlation between VFA and clinical parameters and the effect of semaglutide on VFA in key subgroups.

METHODS

Participants were Japanese adults aged ≥ 20 years with obesity disease, randomized to once-weekly subcutaneous semaglutide 2.4 mg, semaglutide 1.7 mg, or placebo, plus lifestyle recommendations, for 68 weeks. Correlation between baseline VFA (and change in VFA from baseline to week 68) and clinical parameters (body weight, body mass index [BMI], waist circumference, hepatic parameters, glycated hemoglobin, blood pressure, lipids, high-sensitivity C-reactive protein, and plasminogen activator inhibitor-1 [PAI-1]) was evaluated. Percentage change in VFA between semaglutide and placebo was compared across subgroups.

RESULTS

Among 180 participants (semaglutide 2.4 mg, n = 89; semaglutide 1.7 mg, n = 46; placebo, n = 45), mean VFA was 170.0 cm2 across subgroups. A positive correlation (Pearson's correlation coefficient [r] ≥0.3) was observed between baseline VFA and body weight (r = 0.415), BMI (r = 0.374), and both JASSO and WHO criterion waist circumference (r = 0.458 and r = 0.555). Correlation between changes in VFA and body weight, waist circumference, high-density and very low-density lipoprotein cholesterol, triglycerides, PAI-1, aspartate aminotransferase, and alanine transaminase were observed in ≥ 1 treatment arm. Semaglutide 2.4 mg and 1.7 mg reduced VFA compared with placebo in all subgroups.

CONCLUSIONS

VFA partially correlated with clinical parameters in Japanese adults with obesity disease. Subcutaneous semaglutide was an efficacious treatment option for the reduction of VFA, regardless of clinical characteristics.

TRIAL REGISTRY NAME

CT.gov TRIAL REGISTRATION IDENTIFICATION NUMBER: NCT03811574.

Structured lifestyle modification as an adjunct to obesity pharmacotherapy: there is much to learn

We are at the start of an exciting new era of very effective pharmacotherapy for patients with obesity, with the latest generation of drugs approaching the efficacy of obesity surgery. Clinical trials of obesity drugs tend to emphasise the importance of participation in some form of structured lifestyle intervention for all trial participants. This usually consists of advice to reduce calorie intake and increase moderate to vigorous physical activity. There is strong evidence that structured lifestyle modification programmes improve health in patients with obesity and related disorders. However, there is no specific evidence that they improve the response to obesity medications. This is because of the way that drug trials for patients with obesity have traditionally been designed, with participants in the active drug treatment group being compared to participants on placebo drug treatment, but with both groups always receiving the same structured lifestyle intervention. While this approach is entirely reasonable, it makes it impossible to draw any inferences about the efficacy of structured lifestyle modification to augment the response to drug therapy. Given this genuine equipoise, a critical step in ensuring that our treatment of patients with obesity is robustly evidence-based is to determine whether "drug plus lifestyle" offer any advantage over "drug plus placebo" in large, well-designed and adequately powered clinical trials. We also need to determine the cost-effectiveness of these programmes.

Comparative efficacy and safety of semaglutide 2.4 mg and tirzepatide 5-15 mg in obesity with or without type 2 diabetes: A systematic review of Phase 3 clinical trials

BACKGROUND AND AIMS

Both semaglutide 2.4 mg and tirzepatide have been recently approved for chronic use in obesity. There is a lack of literature comparing the efficacy and safety of both these agents in people with obesity/overweight with or without type 2 diabetes (T2D). We systematically reviewed Phase 3 randomized controlled trials (RCTs) conducted with two agents to synthesize the comparative efficacy and safety outcomes.

METHODS

We systematically searched PubMed electronic databases until December 15, 2024, using selected keywords and Boolean "AND." Subsequently, we compared the most closely matched trials conducted with semaglutide 2.4 mg and tirzepatide through an adjusted (if baseline imbalance in treatment outcome modifiers present) or unadjusted (in the absence of baseline imbalance) indirect treatment comparison method.

RESULTS

We identified one trial each of semaglutide 2.4 mg (STEP-1) and tirzepatide 5, 10, and 15 mg (SURMOUNT-1) in obese or overweight people without T2D and one trial each of semaglutide 2.4 mg (STEP-2) and tirzepatide 10 and 15 mg (SURMOUNT-2) in overweight people with T2D that were almost entirely comparable concerning baseline outcome modifier characteristics. Our unadjusted analysis without individual patients' data found relatively higher (4 and 5.4 % additional) weight loss, HbA1c (-0.4 % additional) reduction, and fewer gastrointestinal side effects (GI S/E) with tirzepatide 10 and 15 mg, respectively, than with semaglutide 2.4 mg, in the intention-to-treat analysis.

CONCLUSION

Tirzepatide 10 and 15 mg are more effective and have fewer GI S/E than semaglutide 2.4 mg. A well-powered head-to-head RCT is currently needed to confirm these findings.

The promise of glucagon-like peptide 1 receptor agonists (GLP-1RA) for the treatment of obesity: a look at phase 2 and 3 pipelines

INTRODUCTION

GLP-1-based therapies have changed the treatment of overweight/obesity. Liraglutide 3.0 mg daily, the first GLP-1 RA approved for treatment of overweight, induced a weight loss of 6-8%, Semaglutide 2.4 mg once weekly improved weight loss to about 12-15%, while the dual GIP/GLP-1 receptor agonist tirzepatide once weekly has induced a weight loss of about 20% in obese people without diabetes.

AREAS COVERED

This review describes results obtained with GLP-1 mono-agonists, GLP-1/GIP dual agonists, GLP-1/glucagon co-agonists, and the triple agonist retatrutide (GIP/GLP-1/glucagon), which have shown beneficial effect both on body weight and steatotic liver disease. A combination of semaglutide (a GLP-1 agonist) and cagrilintide (a long-acting amylin analogue) for weekly administration is currently in phase III development, and so is oral semaglutide and several non-peptide small molecule GLP-1 agonists for oral administration. The adverse events with the GLP-1-based therapies are primarily gastrointestinal and include nausea, vomiting, obstipation, or diarrhea, which often can be mitigated by slow up titration.

EXPERT OPINION

The GLP-1-based therapies will change the treatment of obesity and its comorbidities including steatotic liver disease in the future. Outstanding question is maintenance of the weight loss, possibly pharmacological treatment needs to be life-long.

Comprehensive implementations of multiple imputation using retrieved dropouts for continuous endpoints

BACKGROUND

In the metabolic disease area, there has been a long-time debate against using mixed models for repeated measures (MMRM) as the primary analysis of longitudinal continuous endpoints. As missing data arising from missing not at random assumptions are not addressed in MMRM, multiple imputation based on specific assumptions has been brought into play. Among many missing not at random assumptions with varying degrees of conservativeness, multiple imputation based on retrieved dropouts (MIRD) has been accepted by regulatory agencies in several type 2 diabetes and chronic weight management products in recent years, marking the beginning of a new standard for analysis of longitudinal data in this disease area.

METHODS

On top of the established MIRD approach of which the imputation is based on last on-treatment data of retrieved dropout (RD)s, we propose a new class of MIRD approaches utilizing all available data from RDs. The imputation implementation can be one-step Markov Chain Monte Carlo (MCMC) or two-step (creating monotone missingness, followed by regression approach). ANCOVA can be applied to the complete dataset post imputation and Rubin's rule can be used to combine all estimates into a single estimate. Simulation studies in a wide range of scenarios are conducted to understand the type-I error and power rates of the new class versus the established MIRD approach and other reference statistical methods such as MMRM.

RESULTS

Overall, the new class has very similar performance compared to the established MIRD approach based on last on-treatment data. What's more interesting is the one-step MCMC approach has better controlled type-I error and is more powerful than the established MIRD approach in certain scenarios with the difference gradually diminishing with larger sample size. The data analyses based on two real phase 3 datasets further manifest the power conclusions, with the results based on the new class applied to the larger of the two datasets almost identical to that of on-study MMRM.

CONCLUSIONS

We have presented comprehensive implementations of the MIRD approach for continuous endpoints in a longitudinal setting that fully fit within the strategy of treatment policy. The proposed new class based on all observed data of RDs is proved to be as powerful as the established MIRD approach based on last on-treatment visit in most scenarios. The one-step MCMC approach is more powerful than the established MIRD approach in certain scenarios. Since the new class involves less programming derivation of additional flags, it's anticipated to be more easily implemented in clinical trial reporting.

The blood pressure-lowering property of subcutaneous semaglutide: a systematic review, meta-analysis, and meta-regression

PURPOSE

Semaglutide is a glucagon-like peptide (GLP1) receptor agonist with unprecedented weight-lowering and anti-hyperglycemic properties. Recent clinical trials reported that subcutaneous semaglutide can modulate blood pressure; however, its effect on blood pressure widely varied in different studies and different subgroups of patients.

METHODS

PubMed, Web of Science, Scopus, and the Cochrane Library were systematically searched from the inception to July 18, 2024. Due to high heterogeneity, a random-effects model was adopted to pool data.

RESULTS

Twenty clinical trials with 15,312 participants in the placebo group and 18,231 participants in the semaglutide group were included in this study. Subcutaneous semaglutide significantly decreased both systolic (WMD - 3.71 mmHg, 95% CI (-4.29, -3.13), I2: 50.2%) and diastolic (WMD - 1.10 mmHg, 95% CI (-1.58, -0.63), I2: 69.7%) blood pressure. Subgroup analyses indicated that the blood pressure-lowering property of subcutaneous semaglutide was greater among patients without diabetes, with lower baseline hemoglobin A1c (HbA1c), baseline body mass index (BMI) greater than 35 kg/m2, dose of semaglutide more than 1 mg/week, baseline systolic blood pressure equal or less than 130 mmHg, weight loss greater than 10 kg, and BMI reduction greater than 3 kg/m2. In addition, a treatment length of 50 to 100 weeks was associated with greater blood pressure-lowering effects in subgroup analysis. After adjusting for other factors, meta-regression revealed that placebo-adjusted weight change was independently correlated with the effect of semaglutide on systolic and diastolic blood pressure.

CONCLUSION

Subcutaneous semaglutide can significantly decrease systolic and diastolic blood pressure, particularly in selected groups of patients.

Long-Term Clinical and Economic Effects of Switching to Once-Weekly Semaglutide from Other GLP-1 RAs Among Patients with Type 2 Diabetes in China: A Modeling Projection Study

INTRODUCTION

Previous studies, using clinical trial data, demonstrated that once-weekly (OW) semaglutide is dominant versus other glucagon-like peptide 1 receptor agonists (GLP-1 RAs) in China. This study aims to evaluate the long-term clinical and economic effects of switching to OW semaglutide from other GLP-1 RAs among patients with type 2 diabetes mellitus (T2DM) in China.

METHODS

The Institute of Health Economics Diabetes Cohort Model (IHE-DCM) was used to project life expectancy, quality-adjusted life years (QALYs), and total direct medical cost over 40 years from a Chinese healthcare system perspective. Baseline characteristics, clinical effectiveness, and the treatment dose of OW semaglutide were derived from previously real-world studies. Patients were assumed to switch to semaglutide or continue previous GLP-1 RAs for 3 years and change to intensive therapy. Drug prices were based on the median bidding price in January 2024 in China. Costs of other GLP-1 RAs were calculated on the basis of their market share in China. All costs were accounted as 2023 Chinese yuan (CNY). A discount of 5% was applied. One-way sensitivity analyses and probabilistic sensitivity analyses were used to test the robustness of the base-case result.

RESULTS

The results show that switching to OW semaglutide from other GLP-1 RAs among patients with T2DM in China can improve life expectancy by 0.02 years and afford an additional 0.12 QALYs per patient. Meanwhile, switching to OW semaglutide is associated with decreased total lifetime direct medical costs of 4204 CNY per patient, mainly resulting from savings in microvascular costs (2214 CNY) and macrovascular costs (1228 CNY). Sensitivity analyses show the robustness of modeling projection findings.

CONCLUSION

Based on real-world data from China, this modeling projection study demonstrates that switching to OW semaglutide from other GLP-1 RAs can have better clinical and economic effects for patients with T2DM in China, indicating it as a dominant treatment choice.

Kidney fat by magnetic resonance spectroscopy in type 2 diabetes with chronic kidney disease

BACKGROUND AND HYPOTHESIS

The kidneys may be susceptible to ectopic fat and its lipotoxic effects, disposing them to chronic kidney disease (CKD) in type 2 diabetes (T2D). We investigated whether the kidney parenchyma fat content and kidney sinus fat volume would be higher in persons with T2D and CKD.

METHODS

Cross-sectional study including 29 controls, 27 persons with T2D and no CKD, and 48 persons with T2D and early CKD (urine albumin creatinine ratio (UACR) ≥ 30 mg/g). Kidney parenchyma fat content and kidney sinus fat volume were assessed using magnetic resonance spectroscopy and Dixon scans respectively.

RESULTS

In the control, T2D without CKD and T2D with CKD groups, respectively, median [1st - 3rd quartile] UACR was 5 [4 - 6], 6 [5 - 10] and 95 [43 - 278] mg/g. and mean ± standard deviation estimated glomerular filtration rate was 89 ± 11, 94 ± 11 and 77 ± 22 ml/min/1.73m2. Kidney parenchyma fat content was, respectively, 1.0 [0.5-2.4], 0.7 [0.2-1.2], 1.0 [0.3-2.0] % (p = 0.26). Kidney sinus fat volume was 2.8 [1.6-7.6], 8.0 [4.7-11.3], 10.3 [5.7-14.0] ml (p < 0.01). Around 90 % of T2D participants received a sodium-glucose cotransporter-2 inhibitor or glucagon-like peptide-1 receptor agonist.

CONCLUSIONS

In a setting of modern, multifactorial T2D management, kidney parenchyma fat content, evaluated with magnetic resonance spectroscopy, was similar among healthy controls and persons with T2D irrespective of CKD status. Still, kidney sinus fat volume was higher in the presence of T2D and higher still with CKD.

Effects of glucagon-like peptide-1 receptor agonists on blood pressure in overweight or obese patients: a meta-analysis of randomized controlled trials

INTRODUCTION

Glucagon-like peptide-1 receptor agonists are novel medications with proven efficacy in treating type 2 diabetes mellitus, and are increasingly being used for weight loss. They may potentially have benefit in treating metabolic disorders; however, evidence is sparse with regards to treating high blood pressure (BP). We performed a systematic review, meta-analysis and meta-regression investigating the efficacy of GLP-1 RAs in lowering BP in obese or overweight patients.

METHODS

Three electronic databases (PubMed, EMBASE, and CENTRAL) were systematically searched for randomized controlled trials (RCTs) published from inception to 13 February 2024. Pair-wise meta-analysis and random effects meta-regression models were utilized. Fixed effects meta-analysis was used to unify treatment effects across different GLP-1 RA doses.

RESULTS

We included a total of 30 RCTs with a combined population of 37 072 patients. GLP-1 RAs demonstrated a mean systolic BP (SBP) reduction of -3.37 mmHg [95% confidence interval (CI) -3.95 to -2.80] and a mean diastolic BP (DBP) reduction of -1.05 mmHg (95% CI -1.46 to -0.65) compared with placebo. This effect was consistent across subgroups for diabetic status, formulation of GLP-1 RA, follow-up duration and route of administration for both SBP and DBP, with the exception of subgroups investigating exenatide. Meta-regression suggested no significant correlation between BP reduction and baseline characteristics such as age, percentage of male patients, HbA1c, weight, BMI, and percentage of patients with hypertension.

CONCLUSION

Our meta-analysis suggests significant BP reduction benefits from GLP-1 RA use in obese or overweight patients, consistent across diabetic status, duration of treatment, and across route of administration.

Effect of semaglutide 2.4 mg on use of antihypertensive and lipid-lowering treatment in five randomized controlled STEP trials

OBJECTIVE

The objective of this study was to assess antihypertensive and lipid-lowering treatment changes in participants receiving semaglutide 2.4 mg versus placebo across pooled populations from five Semaglutide Treatment Effect in People with Obesity (STEP) trials.

METHODS

Efficacy and safety of semaglutide 2.4 mg were evaluated in the STEP clinical trials. In this post hoc analysis, STEP 1, 3, 6, and 8 (which included people with overweight or obesity) and, separately, STEP 2 and 6 (which included people with overweight or obesity and type 2 diabetes) were pooled for analysis. Changes in antihypertensive or lipid-lowering treatment intensity from randomization to end of treatment were evaluated.

RESULTS

In both pooled samples, a higher proportion of participants in the semaglutide 2.4 mg group versus placebo underwent antihypertensive or lipid-lowering treatment intensity reduction by end of treatment. A smaller proportion underwent antihypertensive or lipid-lowering treatment intensification by end of treatment in the semaglutide 2.4 mg group of both samples versus placebo. In participants receiving antihypertensive or lipid-lowering medications in both samples, greater numeric reductions in body weight were observed in the semaglutide 2.4 mg group versus placebo.

CONCLUSIONS

These results support a relationship between semaglutide 2.4 mg treatment of overweight and obesity and reduced need for antihypertensive and lipid-lowering treatment, facilitating treatment intensity reduction/discontinuation and abating treatment intensification.

Investigating the role of the metabolic score for visceral Fat in assessing the prevalence of chronic kidney disease from the NHANES 1999-2018

This study investigates the association between the Metabolic Score for Visceral Fat (METS-VF) and chronic kidney disease (CKD), assessing METS-VF as a potential predictor of CKD risk. Utilizing data from the 1999-2018 National Health and Nutrition Examination Survey (NHANES), this cross-sectional study included 24,387 adult participants. Multivariable logistic regression, restricted cubic spline models, and threshold effect analyses were employed to explore the relationship. The results revealed a significant positive association, with multivariable logistic regression showing that each unit increase in METS-VF was associated with an 86% higher risk of CKD (OR: 1.86, 95% CI: 1.48-2.34). Critical METS-VF thresholds (6.10 and 7.55) were identified, at which CKD risk increased substantially. Subgroup analyses indicated that the association was particularly pronounced among older adults and males. These findings suggest that METS-VF is a reliable predictor for assessing CKD risk and that lifestyle interventions, including dietary modifications and exercise programs, may mitigate this risk.

An Overview of Existing and Emerging Weight-Loss Drugs to Target Obesity-Related Complications: Insights from Clinical Trials

Obesity requires treatment as it is associated with health problems such as type 2 diabetes, hypertension, dyslipidemia, cardiovascular diseases, and some cancers, which increase mortality rates. Achieving sufficient weight loss to reduce obesity-related diseases requires a variety of interventions, including comprehensive lifestyle modification of diet and exercise, change in behavior, anti-obesity medications, and surgery. To date, anti-obesity agents with various mechanisms of action have been developed, and mostly reduce energy intake, resulting in weight loss of about 5% to 10% compared to baseline. Recently developed drugs and those currently under development have been shown to reduce body weight by more than 10% and are expected to reduce obesity-related complications. This article summarizes existing and emerging anti-obesity medications, with a particular focus on those evaluated in clinical trials.

Glucagon-like Peptide-1 Receptor Agonists in the Management of Diabetic Retinopathy

Glucagon-like peptide-1 (GLP-1) receptor agonists are a family of drugs, most well known by the third-generation once-weekly subcutaneous semaglutide, that act on the incretin pathway of metabolic, hormonal signaling to modulate pancreatic insulin release, gastric emptying, energy intake, and subjective feelings of satiety. This class of drugs' efficacy and safety in the treatment of type 2 diabetes and obesity have been demonstrated across multiple large randomized controlled trials. These data have propelled GLP-1 receptor agonists to ubiquity in diabetic management and weight loss therapy, leading them to be frequently encountered in ophthalmic practice. The effect of GLP-1 receptor agonists like semaglutide on diabetic retinopathy (DR) is at this point unclear; some studies indicate a worsening of DR with the initiation of GLP-1 agonists, especially semaglutide. Overall, the macrovascular reduction of cardiovascular and stroke risks from GLP-1 receptor agonists should be prioritized over the potential microvascular progression of DR, as long as the patient is regularly followed by ophthalmology.

Smart control lipid-based nanocarriers for fine-tuning gut hormone secretion

Modulating the endogenous stores of gastrointestinal hormones is considered a promising strategy to mimic gut endocrine function, improving metabolic dysfunction. Here, we exploit mouse and human knock-in and knockout intestinal organoids and show that agents used as commercial lipid excipients can activate nutrient-sensitive receptors on enteroendocrine cells (EECs) and, when formulated as lipid nanocarriers, can bestow biological effects through the release of GLP-1, GIP, and PYY from K and L cells. Studies in wild-type, dysglycemic, and gut Gcg knockout mice demonstrated that the effect exerted by lipid nanocarriers could be modulated by varying the excipients (e.g., nature and quantities), the formulation methodology, and their physiochemical properties (e.g., size and composition). This study demonstrates the therapeutic potential of using nanotechnology to modulate release of multiple endogenous hormones from the enteroendocrine system through a patient-friendly, inexpensive, and noninvasive manner.

Obstructive sleep apnea and obesity: A review of epidemiology, pathophysiology and the effect of weight-loss treatments

Despite the commonly-accepted paradigm that patients with obstructive sleep apnea (OSA) also invariably have obesity, OSA prevalence extends beyond obesity. This necessitates a reevaluation of screening strategies, biomarkers of increased OSA risk, and heightened awareness among healthcare providers about the array of OSA treatments for diverse adult populations. While obesity contributes importantly to OSA pathogenesis, there is substantial evidence that non-anatomical factors also play a crucial role, especially in patients who do not have obesity. In recent years, notwithstanding the recognition of diverse contributors to OSA pathogenesis, research has frequently focused on weight reduction to address OSA. Insights from past experiences with bariatric surgery in OSA serve as a lens to anticipate potential outcomes of emerging anti-obesity pharmacotherapies. Pharmacological alternatives, particularly incretin agonists, exhibit promise in weight reduction and OSA improvement, but encounter obstacles such as potential side effects and high costs. With this comprehensive narrative review, we delve into the complex epidemiological and pathophysiological connections between OSA and obesity. Additionally, we emphasize the importance of a multifaceted approach to OSA treatment, recognizing that while weight management is crucial, there is a need for comprehensive strategies that go beyond traditional weight-centric perspectives.

Are the lipid-lowering effects of incretin-based therapies relevant for cardiovascular benefit?

PURPOSE OF REVIEW

This review examines the impact of glucagon-like peptide 1 receptor agonists (GLP-1RAs) on lipid profiles in individuals with type 2 diabetes mellitus and/or obesity, crucial for optimizing cardiovascular risk management.

RECENT FINDINGS

GLP-1RAs affect lipid levels by reducing intestinal apolipoprotein B48 production and mesenteric lymph flow, while increasing catabolism of apolipoprotein B100. It remains unknown whether these effects are direct or indirect, but the improvements in lipid levels are strongly correlated to the drug-induced weight loss. Clinical trials demonstrate improvements in lipid profiles, with different effects per agent and dose. We deem it unlikely that improved lipid levels are sufficient to explain the beneficial effects of GLP-1RA on cardiovascular risk, especially given the improvement of many other risk factors (body weight, glycemic control, inflammation) while using these agents. Posthoc mediation analyses of large cardiovascular outcome trials may shed some light on the relative importance of each risk factor.

SUMMARY

GLP-1RAs improve lipid profiles in clinical trials, but their complete cardiovascular benefits likely involve multifactorial mechanisms beyond lipid modulation.

Seven glucagon-like peptide-1 receptor agonists and polyagonists for weight loss in patients with obesity or overweight: an updated systematic review and network meta-analysis of randomized controlled trials

PURPOSE

This study aimed to provide evidence-based support and a reference for the efficacy and safety of seven glucagon-like peptide-1 (GLP-1) receptor agonists and polyagonists for weight loss in patients with obesity or overweight through a network meta-analysis.

METHODS

Relevant randomized controlled trials (RCTs) with an intervention duration of at least 16 weeks assessing seven GLP-1 receptor agonists and polyagonists (mazdutide, 6 or 4.5 mg; retatrutide, 12 or 8 mg; tirzepatide, 15 or 10 mg; liraglutide, 3.0 mg; semaglutide, 2.4 mg; orforglipron, 45 or 36 mg; and beinaglutide, 0.2 mg) in patient with obesity or overweight was searched using three databases (Cochrane Library, PubMed, and Embase) from creation to August 30, 2024. The primary outcome was the percentage change in body weight from baseline. Secondary outcomes included changes in waist circumference, hemoglobin A1c, and fasting plasma glucose level from baseline; adverse events, serious adverse events, adverse event withdrawal, and hypoglycemic events. We conducted a frequentist random-effects network meta-analysis to analyze the data extracted from the RCTs using Stata 16.1 software.

RESULTS

Twenty-seven RCTs of seven GLP-1 receptor agonists and polyagonists and 15,584 patients were included in the network meta-analysis. In terms of efficacy, compared with placebo, retatrutide 12 mg (-22.10 % in body weight and - 17.00 cm in waist circumference), retatrutide 8 mg (-20.70 % and - 15.90 cm), and tirzepatide 15 mg (-16.53 % and - 13.23 cm) were the three most efficacious treatments for reducing body weight and waist circumference. However, these treatments were less effective in patients with type 2 diabetes mellitus (T2DM). In addition, patients with a high body mass index (BMI) or longer treatment cycles exhibited significantly greater weight loss than those with a low BMI or shorter treatment cycles. In terms of safety, patients without T2DM had a higher incidence of adverse events than those with T2DM. None of the interventions increased the incidence of serious adverse or hypoglycemic events (˂54 mg/dL). There was no significant difference in the incidence of adverse event withdrawal for all interventions in head-to-head comparisons. In addition, disparities in race, BMI, and treatment cycles did not significantly increase the incidence of adverse events. Finally, the sensitivity and publication bias analyses indicated that the basic analysis results were reliable.

CONCLUSION

Retatrutide (both doses) and tirzepatide exhibited superior efficacy compared to other GLP-1 receptor agonists and polyagonists in reducing body weight and waist circumference. Patients without T2DM, those with a high BMI, and individuals undergoing longer treatment cycles demonstrated significantly greater weight loss and reductions in waist circumference. Dual or triple receptor agonists (GLP-1 plus glucose-dependent insulinotropic polypeptide and/or Glucagon receptor) are more effective for weight loss than GLP-1 receptor agonists.

Associations of metabolic disorders with hypertension and cardiovascular disease: recent findings and therapeutic perspectives

We theoretically know that metabolic disorders, including overweight/obesity, insulin resistance, diabetes, dyslipidemia, and relevant tissue/organ damage, play a critical role in elevating blood pressure and developing hypertension. However, staying abreast of the ever-evolving and current research on the various metabolic disorder topics is difficult. At the same time, as hypertension in childhood and adolescence is attracting significant attention globally, it is becoming increasingly evident that metabolic disorders exert an important role in its pathogenesis. In order to effectively prevent hypertension, it is essential to appropriately approach metabolic disorders, and importantly, this approach must be practiced continuously throughout all generations. Thus, focusing on metabolic disorders is the first and essential step in effectively managing and preventing hypertension. In this Mini-Review, we introduce cutting-edge research findings on "Metabolism," published in 2023 by Hypertension Research, and discuss relevant topics and therapeutic and future perspectives.

Recent achievements and future directions of anti-obesity medications

Pharmacological management of obesity long suffered from a reputation of a 'Mission Impossible,' with inefficient weight loss and/or unacceptable tolerability. However, the tide has turned with recent progress in biochemical engineering and the development of long-acting agonists at the receptor for glucagon-like peptide-1 (GLP-1), and with unimolecular peptides that simultaneously possess activity at the receptors for GLP-1, the glucose-dependent insulinotropic polypeptide (GIP) and glucagon. Some of these novel therapeutics not only improve body weight and glycemic control in individuals with obesity and type 2 diabetes with hitherto unmet efficacy and tolerable safety, but also exhibit potential therapeutic value in diverse areas such as neurodegenerative diseases, fatty liver disease, dyslipidemia, atherosclerosis, and cardiovascular diseases. In this review, we highlight recent advances in incretin-based therapies and discuss their pharmacological potential within and beyond the treatment of obesity and diabetes, as well as their limitations in use, side effects, and underlying molecular mechanisms.

Glucagon-like peptide-1 receptor agonist semaglutide reduces atrial fibrillation incidence: A systematic review and meta-analysis

BACKGROUND

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are new anti-hyperglycaemic drugs with proven cardiovascular (CV) benefit in diabetic and non-diabetic patients at high CV risk. Despite a neutral class effect on arrhythmia risk, data on semaglutide suggest a possible drug-specific benefit in reducing atrial fibrillation (AF) occurrence.

OBJECTIVE

To perform a meta-analysis of randomized clinical trials (RCTs) to assess the risk of incident AF in patients treated with semaglutide compared to placebo.

METHODS AND RESULTS

Ten RCTs were included in the analysis. Study population encompassed 12,651 patients (7285 in semaglutide and 5366 in placebo arms), with median follow-up of 68 months. A random effect meta-analytic model was adopted to pool relative risk (RR) of incident AF. Semaglutide reduces the risk of AF by 42% (RR .58, 95% CI .40-.85), with low heterogeneity across the studies (I2 0%). At subgroup analysis, no differences emerged between oral and subcutaneous administration (oral: RR .53, 95% CI .23-1.24, I2 0%; subcutaneous: RR .59, 95% CI .39-.91, I2 0%; p-value .83). In addition, meta-regression analyses did not show any potential influence of baseline study covariates, in particular the proportion of diabetic patients (p-value .14) and body mass index (BMI) (p-value .60).

CONCLUSIONS

Semaglutide significantly reduces the occurrence of incident AF by 42% as compared to placebo in individuals at high CV risk, mainly affected by type 2 diabetes mellitus. This effect appears to be consistent independently of the route of administration of the drug (oral or subcutaneous), the presence of underlying diabetes and BMI.

The effect of GLP-1R agonists on the medical triad of obesity, diabetes, and cancer

Glucagon-like peptide-1 receptor (GLP-1R) agonists have garnered significant attention for their therapeutic potential in addressing the interconnected health challenges of diabetes, obesity, and cancer. The role of GLP-1R in type 2 diabetes mellitus (T2DM) is highlighted, emphasizing its pivotal contribution to glucose homeostasis, promoting β-cell proliferation, and facilitating insulin release. GLP-1R agonists have effectively managed obesity by reducing hunger, moderating food intake, and regulating body weight. Beyond diabetes and obesity, GLP-1R agonists exhibit a multifaceted impact on cancer progression across various malignancies. The mechanisms underlying these effects involve the modulation of signaling pathways associated with cell growth, survival, and metabolism. However, the current literature reveals a lack of in vivo studies on specific GLP-1R agonists such as semaglutide, necessitating further research to elucidate its precise mechanisms and effects, particularly in cancer. While other GLP-1R agonists have shown promising outcomes in mitigating cancer progression, the association between some GLP-1R agonists and an increased risk of cancer remains a topic requiring more profound investigation. This calls for more extensive research to unravel the intricate relationships between the GLP-1R agonist and different cancers, providing valuable insights for clinicians and researchers alike.

Representation of racialised and ethnically diverse populations in multicentre randomised controlled trials of GLP-1 medicines for obesity: a systematic review and meta-analysis of gaps

INTRODUCTION

Trials of GLP-1 (glucagon-like peptide-1) medicines have changed the paradigm of obesity treatment. Diversity in trial participation is imperative considering that obesity disproportionately impacts marginalised populations worldwide. We performed a systematic review and meta-analyses to evaluate the representation of racialised and ethnically diverse populations in randomised controlled trials (RCTs) of GLP-1 medicines for obesity.

METHODS

We searched PubMed/Embase/ClinicalTrials.gov. Prevalence of each racial/ethnic group was compared in relation to the USA, Canada, the UK, Brazil and South Africa. The geographical locations of the trial sites were extracted.

RESULTS

27 RCTs were identified (n=21 547 participants). Meta-analyses of prevalence demonstrated the vast predominance of white/Caucasians (79%) with smaller proportion of blacks (9%), Asians (13%), Indigenous (2%) and Hispanics (22%). The gaps in representation were evidenced by the significantly under-represented proportion of non-white individuals in these RCTs as compared with the prevalence of non-white individuals in the general population of the USA (-23%, p=0.002) and Canada (-34%, p<0.0001), reaching an alarming gap of -58% in relation to Brazil and striking under-representation of -68% as compared with South Africa. Similar discrepancies in proportions of blacks, Asians and Indigenous peoples as compared with reference nations were found. Moreover, the trial sites (n=1859) were predominately located in high-income countries (84.2%), in sharp contrast to the global prevalence of obesity that is predominantly in low-income and middle-income countries.

CONCLUSION

There are discrepancies in representation of racialised and ethnically diverse populations in obesity trials as compared with multiethnic populations worldwide. These data highlight the need for broader reform in the research process in order to ultimately address health inequities.

Efficacy and Safety of GLP-1 Medicines for Type 2 Diabetes and Obesity

The development of glucagon-like peptide 1 receptor agonists (GLP-1RA) for type 2 diabetes and obesity was followed by data establishing the cardiorenal benefits of GLP-1RA in select patient populations. In ongoing trials investigators are interrogating the efficacy of these agents for new indications, including metabolic liver disease, peripheral artery disease, Parkinson disease, and Alzheimer disease. The success of GLP-1-based medicines has spurred the development of new molecular entities and combinations with unique pharmacokinetic and pharmacodynamic profiles, exemplified by tirzepatide, a GIP-GLP-1 receptor coagonist. Simultaneously, investigational molecules such as maritide block the GIP and activate the GLP-1 receptor, whereas retatrutide and survodutide enable simultaneous activation of the glucagon and GLP-1 receptors. Here I highlight evidence establishing the efficacy of GLP-1-based medicines, while discussing data that inform safety, focusing on muscle strength, bone density and fractures, exercise capacity, gastrointestinal motility, retained gastric contents and anesthesia, pancreatic and biliary tract disorders, and the risk of cancer. Rapid progress in development of highly efficacious GLP-1 medicines, and anticipated differentiation of newer agents in subsets of metabolic disorders, will provide greater opportunities for use of personalized medicine approaches to improve the health of people living with cardiometabolic disorders.

Reconsidering Semaglutide Use for Chronic Obesity in Patients of Asian Descent: A Critical Review

Semaglutide is a glucagon-like peptide 1 (GLP-1) receptor agonist. It is the first approved drug for chronic weight management in adults who are overweight or obese since 2014. Its increasing popularity has garnered significant media attention and led to a drug shortage, resulting in limited access for its intended use - patients with type 2 diabetes. Numerous studies have demonstrated its effectiveness in promoting weight loss. This review seeks to explain the use of semaglutide, a GLP-1 receptor agonist, to treat metabolic syndrome in the Asian American population. It raises concerns about the existing diagnostic and treatment approaches and stresses the necessity of integrating visceral fat and other ethnicity-specific risk predictors for the diagnosis of metabolic syndrome. The objective of this review is to examine the eligibility criteria for the prescription of semaglutide critically and determine whether Asians are being unfairly excluded and denied access to this medication due to ineffective prescription guidelines.

Clinical characteristics affecting weight loss in an East Asian population receiving semaglutide: A STEP 6 subgroup analysis

OBJECTIVE

To explore the effects of semaglutide versus placebo on body weight (BW) by subgroups of baseline characteristics.

METHODS

In STEP 6, Japanese and Korean adults with overweight or obesity were randomized to subcutaneous semaglutide 2.4 mg, semaglutide 1.7 mg, or placebo for 68 weeks. A subset of Japanese participants with type 2 diabetes (T2D) was also included. In this post-hoc analysis, change from baseline in BW (%) was assessed by subgroups of baseline characteristics including baseline BW, body mass index, age, sex, glycemic status, dyslipidemia, and hypertension.

RESULTS

Of 401 participants (148 female and 253 male) included, the estimated mean change in BW was clinically relevant across all subgroups for semaglutide 2.4 mg, ranging from -9.40 % to -16.42 %. Estimated treatment differences also favored both semaglutide doses versus placebo. Significant treatment-by-subgroup interactions were observed for sex with semaglutide 1.7 mg and 2.4 mg versus placebo at week 68 (p = 0.0008 and p = 0.0005, respectively). Significant treatment-by-subgroup interactions were also observed for presence of T2D and dyslipidemia at baseline, for semaglutide 2.4 mg versus placebo only (p = 0.0381 and p = 0.0181, respectively).

CONCLUSIONS

Semaglutide reduces BW in a wide demographic of people with a range of weight-related comorbidities in an East Asian population.

Once-Weekly Semaglutide in Persons with Obesity and Knee Osteoarthritis

BACKGROUND

Weight reduction has been shown to alleviate symptoms of osteoarthritis of the knee, including pain. The effect of glucagon-like peptide-1 receptor agonists on outcomes in knee osteoarthritis among persons with obesity has not been well studied.

METHODS

We conducted a 68-week, double-blind, randomized, placebo-controlled trial at 61 sites in 11 countries. Participants with obesity (a body-mass index [BMI; the weight in kilograms divided by the square of the height in meters] of ≥30) and a clinical and radiologic diagnosis of moderate knee osteoarthritis with at least moderate pain were randomly assigned, in a 2:1 ratio, to receive once-weekly subcutaneous semaglutide (2.4 mg) or placebo, in addition to counseling on physical activity and a reduced-calorie diet. The primary end points were the percentage change in body weight and the change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score (on a scale of 0 to 100, with higher scores reflecting worse outcomes) from baseline to week 68. A key confirmatory secondary end point was the physical-function score on the 36-Item Short Form Health Survey (SF-36), version 2 (on a scale of 0 to 100, with higher scores indicating greater well-being).

RESULTS

A total of 407 participants were enrolled. The mean age was 56 years, the mean BMI 40.3, and the mean WOMAC pain score 70.9. A total of 81.6% of the participants were women. The mean change in body weight from baseline to week 68 was -13.7% with semaglutide and -3.2% with placebo (P<0.001). The mean change in the WOMAC pain score at week 68 was -41.7 points with semaglutide and -27.5 points with placebo (P<0.001). Participants in the semaglutide group had a greater improvement in SF-36 physical-function score than those in the placebo group (mean change, 12.0 points vs. 6.5 points; P<0.001). The incidence of serious adverse events was similar in the two groups. Adverse events that led to permanent discontinuation of the trial regimen occurred in 6.7% of the participants in the semaglutide group and in 3.0% in the placebo group, with gastrointestinal disorders being the most common reason for discontinuation.

CONCLUSIONS

Among participants with obesity and knee osteoarthritis with moderate-to-severe pain, treatment with once-weekly injectable semaglutide resulted in significantly greater reductions in body weight and pain related to knee osteoarthritis than placebo. (Funded by Novo Nordisk; STEP 9 ClinicalTrials.gov number, NCT05064735.).