Use of oral combination therapy for type 2 diabetes in primary care: Meeting individualized patient goals

Design expert software assisted development and evaluation of empagliflozin and sitagliptin combination tablet with improved in-vivo anti-diabetic activities

Background

The combination of empagliflozin and sitagliptin to treat type-2 diabetes might be more economical and patient compliance with an additive improvement in glycemic control due to complementary modes of action.

Aim of the study

To design, formulate and optimize an immediate tablet dosage form containing empagliflozin and sitagliptin utilizing statistically reliable study design followed by in-vitro and in-vivo testing.

Method

ology: To determine the effects of copovidone (X1) and croscarmellose sodium (X2) amounts on the dependent variables of disintegration time and percent drug release, the formulation was developed using Design Expert Software v.13's direct compression method-based central composite design optimization study. The formulations' assay, dissolution, friability, hardness, weight variation, disintegration, and anti-diabetic effects were evaluated in comparison to the standard drug. The analysis included the use of high performance liquid chromatography (HPLC) assay methods. Mice were employed to investigate the efficacy of an anti-diabetic drug after they were administered a high-fat diet and two injections of streptozotocin at a dosage of 30 mg/kg BW each.

Results

Formulation of F3 out of nine had all in-vitro parameters at the most satisfactory condition. It was found that assay of the best formulation is 100.99% and 100.19% for empagliflozin and sitagliptin respectively. The disintegration time of F3 was found at 5.32 min. Percentage release of empagliflozin in 30 min was found 89.05% while sitagliptin was with 93.76%. The results showed that administration of F3 significantly reduced FBG (68.61%, p < 0.0001), total cholesterol levels (70.29 ± 0.48; p < 0.0001), triglycerides (70.20 ± 0.40, p < 0.0001); HDL levels (52.50 ± 0.31; p < 0.0001), LDL levels (33.34 ± 0.28; p < 0.0001), compared to diabetic control, this effect was comparable to metformin treatment.

Conclusion

The direct compression approach has been used to develop, and optimize a new combination tablet incorporating empagliflozin and sitagliptin with better dissolution rate and anti-diabetic action.

Compound combinations targeting longevity: Challenges and perspectives

Aging is one of the world's greatest concerns, requiring urgent, effective, large-scale interventions to decrease the number of late-life chronic diseases and improve human healthspan. Anti-aging drug therapy is one of the most promising strategies to combat the effects of aging. However, most geroprotective compounds are known to successfully affect only a few aging-related targets. Given this, there is a great biological rationale for the use of combinations of anti-aging interventions. In this review, we characterize the various types of compound combinations used to modulate lifespan, discuss the existing evidence on their role in life extension, and present some key points about current challenges and future prospects for the development of combination drug anti-aging therapy.

Recommendations for Early and Comprehensive Management of Type 2 Diabetes and Its Related Cardio-Renal Complications

Type 2 diabetes (T2D) is a global health problem accompanied by an elevated risk of complications, the most common being cardiac and renal diseases. In Lebanon, the prevalence of T2D is estimated at 8-13%. Local medical practice generally suffers from clinical inertia, with gaps in the yearly assessment of clinical manifestations and suboptimal screening for major complications. The joint statement presented here, endorsed by five Lebanese scientific medical societies, aims at providing physicians in Lebanon with a tool for early, effective, and comprehensive care of patients with T2D. Findings from major randomized clinical trials of antidiabetic medications with cardio-renal benefits are presented, together with recommendations from international medical societies. Optimal care should be multidisciplinary and should include a multifactorial risk assessment, lifestyle modifications, and a regular evaluation of risks, including the risks for cardiovascular (CV) and renal complications. With international guidelines supporting a shift in T2D management from glucose-lowering agents to disease-modifying drugs, the present statement recommends treatment initiation with metformin, followed by the addition of sodium-glucose cotransporter 2 inhibitors or glucagon-like peptide-1 receptor agonists due to their CV and renal protection properties, whenever possible. In addition to the selection of the most appropriate pharmacological therapy, efforts should be made to provide continuous education to patients about their disease, with the aim to achieve a patient-centered approach and to foster self-management and adherence to the medical plan. Increasing the level of patient engagement is expected to be associated with favorable health outcomes. Finally, this statement recommends setting an achievable individualized management plan and conducting regular follow-ups to monitor the patients' glycemic status and assess their risks every 3-6 months.

Development of Bilayer Tablet Containing Saxagliptin Immediate Release and Metformin Sustained Release Using Quality by Design Approach

Objective:

Adequate glycemic control in diabetes patients requires oral combination therapy. Saxagliptin is a dipeptidyl peptidase-4 inhibitor having fewer adverse effects, and metformin is the first-line medicine for diabetes treatment. The aim of this research work is to develop a bilayer tablet of saxagliptin and metformin in fixed-dose combination (FDC) using quality by design (QbD) to acquire the immediate release of saxagliptin and sustained release of metformin from bilayer tablet to ultimately achieve superior patient compliance.

Methods:

The development of the bilayer tablet was done in four stages using QbD. In the first step, quality target product profile (QTPP) of bilayer tablet was defined, and critical quality attributes (CQAs) were identified by risk estimation matrix and taguchi design; an immediate release saxagliptin layer was optimized in the second step, optimization of sustained-release metformin layer was carried out in the third step, and in the final step, bilayer tablet was prepared and characterized. The effect of independent parameters, i.e., magnesium stearate level (X1), kneading time (X2) and lubrication time (X3) on Carr’s Index (Y1), percentage relative standard deviation of content uniformity (Y2) and drug release at 30 minutes (Y3), were estimated for optimization of immediate release saxagliptin layer using Box-Behnken design (BBD). The effect of independent parameters, i.e., hydroxypropyl methylcellulose level (X4), compritol level (X5) and magnesium stearate level (X6) on Carr’s Index (Y4), drug release at 2 h (Y5), drug release at 5 h (Y6) and drug release at 10 h (Y7) were estimated for optimization of sustained-release metformin layer using BBD.

Results:

The optimized composition of immediate release saxagliptin layer estimated using numerical optimization by Design expert was 0.88% (X1), 15 minutes (X2) and 3.85 minutes (X3) with predicted variables, i.e., 10.59% (Y1), 3.16% (Y2) and 85% (Y3). The optimized composition of sustained- release saxagliptin layer predicted through numerical optimization was 30% (X4), 3.36% (X5) and 0.9% (X6) having 10.89% (Y4), 43.44% (Y5), 60% (Y6) and 85.14% (Y7). In-vitro dissolution study of bilayer tablet showed immediate release of Saxagliptin (approximately 85% in 30 minutes) and sustained release of metformin illustrating 43.21±1.21, 60.86±2.96 and 86.26±1.38% drug release at 2, 5 and 10 h, respectively. The release exponent for the Korsmeyer-Peppas model for Saxagliptin and metformin was 0.237 (<0.45) and 1.536 (n>0.85), indicating Fickian and super case II transport drug release behavior, respectively.

Conclusion:

By QbD approach, bilayer tablet containing saxagliptin and metformin was successfully developed, and influence of various formulation parameters on CQAs of drug products was understood with fewer experiments. This leads to the conclusion that cost can be reduced using QbD in the development of FDC for improving patient compliance.

The perspectives of physicians regarding antidiabetic therapy de-intensification and factors affecting their treatment choices-A cross-sectional study

AIMS

Comprehensive diabetes management may include treatment intensification or the administration of antidiabetic combination therapy. However, this may be associated with an increased risk of adverse events and death. The aim of this study was to understand physicians' perspectives regarding treatment de-intensification, HbA1c goals individualisation, and factors affecting their treatment choice for patients with type 2 diabetes mellitus (T2DM).

METHODS

A cross-sectional study was conducted in primary and secondary care units in Saudi Arabia using online questionnaire. Two previously validated questionnaires were used to understand physicians' awareness of, agreement with, and their practices of individualising HbA1c goals and antidiabetic treatment optimisation, and to assess factors affecting physicians' treatment choice when prescribing antidiabetic treatment for patients with type 2 diabetes mellitus. Study population were physicians who are treating patients with diabetes mellitus during the period between October 2017 and May 2018.

RESULTS

A total of 205 physicians have participated in the study. Approximately 50% of physicians had family medicine speciality (n = 98, 47.8%). The majority of physicians (n = 183, 89.3%) were familiar with the concept of HbA1c goals individualisation. However, only 66.3% of them (n = 136) reported that they apply it either always or most of the time. 58.5% (n = 120) of physicians reported that they would not initiate conversations about de-intensifying antidiabetic therapy even if their patients had a stable HbA1c values for one year. Physicians showed higher consideration to objective patient clinical data and their assessment of patient's health status, with minor consideration to patient-related factors.

CONCLUSIONS

Healthcare professionals should focus more on implementing contemporary practices and applying any necessary treatment de-intensification or dose adjustment. Subjective patient factors should be taken into account further, as these factors are associated with better disease management.

Synergistic use of biomaterials and licensed therapeutics to manipulate bone remodelling and promote non-union fracture repair

Disrupted bone metabolism can lead to delayed fracture healing or non-union, often requiring intervention to correct. Although the current clinical gold standard bone graft implants and commercial bone graft substitutes are effective, they possess inherent drawbacks and are limited in their therapeutic capacity for delayed union and non-union repair. Research into advanced biomaterials and therapeutic biomolecules has shown great potential for driving bone regeneration, although few have achieved commercial success or clinical translation. There are a number of therapeutics, which influence bone remodelling, currently licensed for clinical use. Providing an alternative local delivery context for these therapies, can enhance their efficacy and is an emerging trend in bone regenerative therapeutic strategies. This review aims to provide an overview of how biomaterial design has advanced from currently available commercial bone graft substitutes to accommodate previously licensed therapeutics that target local bone restoration and healing in a synergistic manner, and the challenges faced in progressing this research towards clinical reality.

Imeglimin Does Not Induce Clinically Relevant Pharmacokinetic Interactions When Combined with Either Metformin or Sitagliptin in Healthy Subjects

BACKGROUND AND OBJECTIVES

Imeglimin (IMEG) is the first in a novel class of oral glucose-lowering agents with a unique mechanism of action targeting mitochondrial bioenergetics. We assessed whether repeated co-administration of IMEG and either metformin (MET) or sitagliptin (SITA) would influence the pharmacokinetics of either MET or SITA in healthy Caucasian men.

METHODS

Healthy Caucasian men received either MET 850 mg twice daily with placebo (n = 16) or SITA 100 mg once daily with placebo (n = 16) on days 1-6, followed by MET 850 mg twice daily with IMEG 1500 mg twice daily or SITA 100 mg once daily with IMEG 1500 mg twice daily on days 7-12. Pharmacokinetic parameters were determined from blood and urine; levels of all compounds were evaluated using liquid chromatography with tandem mass spectrometry.

RESULTS

Systemic exposure (AUC_0-τ area under the plasma concentration-time curve over a dosing interval and maximum concentration) to MET was 14% and 10% lower, respectively, when administered with IMEG. Approximately 40% of MET was excreted unchanged in urine, decreasing to 34% when given with IMEG. The 90% confidence intervals for AUC_0-τ and maximum concentration indicated no effect of co-administration on systemic exposure to MET. Mean AUC_0-τ and maximum concentration of SITA were similar with or without IMEG. Median times to maximum concentration were 0.7 and 1.0 h and mean elimination half-lives were 8.2 and 8.7 h with and without IMEG, respectively. Systemic exposure to IMEG was similar to previous phase I studies.

CONCLUSIONS

Co-administration of IMEG with MET or SITA did not result in clinically relevant changes in systemic exposure to MET or SITA, although minor reductions in exposure (AUC_0-τ and maximum concentration) and renal elimination were noted when MET was given with IMEG vs placebo.

CLINICAL TRIAL REGISTRATION

EudraCT2009-014520-40 (MET-IMEG DDI) and EudraCT2010-022926-34 (SITA-IMEG DDI).

Benefit-Risk Assessment of Alogliptin for the Treatment of Type 2 Diabetes Mellitus

The dipeptidyl peptidase-4 inhibitor (DPP-4i) alogliptin is an oral, antidiabetic treatment that is approved in many countries to treat patients with type 2 diabetes mellitus (T2DM), including the USA, Europe, and Japan. Alogliptin is efficacious both as monotherapy and as add-on/combination therapy with other commonly prescribed T2DM treatments, such as metformin and pioglitazone. Overall, alogliptin is well-tolerated in patients with T2DM, including older patients, those with renal and/or hepatic impairment, and those at high risk of cardiovascular events. There is a low risk of hypoglycemia, weight gain, acute pancreatitis, and gastrointestinal adverse events with alogliptin treatment, as demonstrated in long-term trials (lasting up to 4.5 years) and in a real-world setting. Additionally, alogliptin has a generally favorable or similar safety profile in comparison to other antidiabetic agents (metformin, thiazolidinediones, sulfonylureas, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter 2 inhibitors, α-glucosidase inhibitors, and insulin). However, further evaluation would be required to determine the mechanism and effect of alogliptin on heart failure, bullous pemphigoid, and inflammatory bowel disease. Of note, due to the ethnic diversity in the epidemiology of T2DM, alogliptin has been shown to be more efficacious in Asian patients than in non-Asian patients with T2DM, but with a similar tolerability profile. These data indicate that DPP-4is, including alogliptin, are important treatment options, especially for Asian patients with T2DM, for whom they have potential as a first-line therapy. This benefit-risk assessment aims to place alogliptin within the current armamentarium of T2DM and aid physicians when choosing optimal diabetes treatment for their patients.

Pathological Role of Advanced Glycation End Products (AGEs) and their Receptor Axis in Atrial Fibrillation

Accumulating evidence has shown that the incidence of atrial fibrillation (AF) is higher in patients with diabetes, especially those with poor glycemic control or long disease duration. Nonenzymatic glycation of amino acids of proteins, lipids, and nucleic acids has progressed under normal aging process and/or diabetic condition, which could lead to the formation and accumulation of advanced glycation end products (AGEs). AGEs not only alter the tertiary structure and physiological function of macromolecules, but also evoke inflammatory and fibrotic reactions through the interaction of cell surface receptor for AGEs (RAGE), thereby being involved in aging-related disorders. In this paper, we briefly review the association of chronic hyperglycemia and type 1 diabetes with the risk of AF and then discuss the pathological role of AGE-RAGE axis in AF and its thromboembolic complications.

Use of multiple antidiabetic medications in patients with diabetes and its association with hypoglycaemic events: a case-crossover study in Jordan

OBJECTIVE

To assess whether the use of multiple antidiabetic medications is associated with an increased risk of hypoglycaemia in patients with type 2 diabetes mellitus.

DESIGN

A case-crossover study.

SETTING

Cases were enrolled from the National Center for Diabetes, Endocrinology and Genetics in Amman, Jordan.

PARTICIPANTS

Patients were those with diabetes mellitus and reported incident of a hypoglycaemic event in their medical records during the period January 2007 to July 2017. Patients with multiple antidiabetic medications were those with at least two antidiabetic medications.

PRIMARY OUTCOME

History of antidiabetic medication use was extracted from the pharmacy records. The use of multiple antidiabetic medications during the risk window (before hypoglycaemia) was compared with a control window(s) (earlier time) of the same length after a washout period. Conditional logistic regression was applied to evaluate the OR of hypoglycaemia between the treatment groups. A secondary analysis was performed in patients with a blood glucose measurement of ≤70 mg/dL.

RESULTS

182 patients (106 females, 58.2%) were included in the study with an average age of 59.9 years (SD=9.9). The patients' average body mass index was 31.7 kg/m² (SD=6.2). Compared with monotherapy, the OR of hypoglycaemic events for patients with multiple antidiabetic medications was 5.00 (95% CI 1.10 to 22.82). The OR was 6.00 (95% CI 0.72 to 49.84) for the secondary analysis patient group (n=94). Ten-fold increased risk was found in patients (n=155) with insulin and sulfonylurea-based combination therapy (OR 10.00;95% CI 1.28 to 78.12).

CONCLUSION

This study shows that the use of multiple antidiabetic medications appears to increase the risk of hypoglycaemic events. Patients and healthcare professionals should be extra vigilant when patients are on multiple antidiabetic medications therapy, especially the combination of sulfonylurea and insulin.

Sodium-glucose Cotransporter-2 Inhibitors in Combination with Other Glucose-lowering Agents for the Treatment of Type 2 Diabetes Mellitus

Involvement of multiple physiological pathways and complex pathogenesis is responsible for the onset and progression of type 2 diabetes mellitus (T2DM). Since it is difficult to manage multiple pathophysiological defects by monotherapy, a combination therapy with two or more oral antidiabetic agents (OADs) may help achieve euglycemia in T2DM patients. Choice of OADs is difficult with growing armamentarium of antidiabetic therapy. Ideally, drug combination should aim at reversal of known pathogenic abnormalities and demonstrate improvement in the overall metabolic health rather than simply reduce glycosylated hemoglobin (HbA1c) levels. Increased glucose reabsorption, a faulty pathological mechanism, is targeted by a novel class of drugs, namely, the sodium-glucose cotransporter-2 (SGLT2) inhibitors. Combination of SGLT2 inhibitors and other OADs complement each other due to their unique mechanism of action. In addition, the glucose-lowering effect of SGLT2 inhibitors remains independent of β-cell function and insulin sensitivity which reduces the chances of severe hypoglycemia in patients receiving these agents. Clinical studies from the past favor the use of SGLT2 inhibitors in combination with other agents to achieve better HbA1c levels, weight loss, and blood pressure control. In this review, we have made an attempt to explore the recommended guidelines for combination therapy, its advantages as either combination therapy or fixed-dose combinations therapy, and the role of SGLT2 inhibitors as a choice of drug as a combination with other OADs.

Improved glycaemic control and lower hypoglycaemia risk with reduced prior oral antidiabetes drug therapy in patients with type 2 diabetes treated with insulin glargine 300 U/mL

AIMS

Data from the EDITION 3 randomized study and the Clinformatics claims database were analysed to determine whether insulin glargine 300 U/mL (Gla-300) could provide insulin-naive patients with type 2 diabetes (T2D) on oral antidiabetes drugs (OADs) with reductions in prior OAD therapy without compromising glycaemic control, and while preserving its known low incidence of hypoglycaemia compared with insulin glargine 100 U/mL (Gla-100).

METHODS

Patient-level data from EDITION 3 and de-identified data from the Clinformatics real-world claims database were analysed.

RESULTS

At baseline, 70% of patients in EDITION 3 were on a background of ≥2 OADs. Among the 435 and 437 patients who initiated basal insulin with Gla-300 and Gla-100, respectively, at Month 6, 336 (77%) and 338 (77%) were using ≤1 OAD. Adding Gla-300 or Gla-100 similarly allowed for a reduction in background OAD medication in the Clinformatics dataset (N = 6430), such that, at 6 months postbasal insulin initiation, 14% of patients were no longer taking any OADs. In the analysis of the EDITION 3 study, reduction in OAD burden did not compromise glycaemic benefit, and the low incidence of hypoglycaemia associated with Gla-300 compared with Gla-100 was also preserved. Documented symptomatic hypoglycaemia (blood glucose ≤70 mg/dL) occurred in 30.5% vs 41.0% of patients treated with Gla-300 and Gla-100, respectively (P = 0.0442).

CONCLUSION

Patients with T2D who initiate basal insulin with Gla-300 could potentially reduce their prior OAD use without compromising glycaemic control and with less hypoglycaemia than with Gla-100.

Choice of Treatment Regimen as Add-On to Insulin in Japanese Patients with Type 2 Diabetes Mellitus: Physicians' Perspective in a Real-World Setting, Insight from a Web Survey

INTRODUCTION

The Japanese guidelines emphasize treatment individualization and intensification with oral anti-diabetes drugs and glucagon-like peptide-1 receptor agonists (OADGs) as add-on therapy to insulin in the management of type 2 diabetes mellitus (T2DM). However, a step-wise treatment algorithm is not clearly defined in the Japanese guidelines. This study explores the treatment factors and patient characteristics for selecting the OADGs as add-on therapy to insulin from physicians' perspectives in a real-world setting in Japan.

METHODS

This web-based survey comprised a questionnaire designed for physicians (diabetologists with board certification and general physicians without board certification) across Japan. The primary endpoint was the proportion of treatment factors and patient characteristics influencing the selection of OADGs as add-on therapy to insulin by the physicians.

RESULTS

In total, 549 physicians participated. The mean number of patients treated with insulin by diabetologists (102.2 ± 91.2) in the past 6 months was higher than the number by general physicians (35.1 ± 44.3). The dipeptidyl peptidase-4 (DPP-4) inhibitors were the most frequently prescribed OADGs as add-on therapy to insulin types among the physicians (75.4-88.2%), followed by metformin (65.2-76.3%). The treatment factors influencing the choice of a DPP-4 inhibitor were glycated hemoglobin (HbA1c) and postprandial glucose (PPG) lowering effect, frequency of administration, effect on glucagon, and ease of use in patients with renal or liver impairment. For metformin, cost-effectiveness was the key deciding factor. The patient characteristics for the choice of DPP-4 inhibitors among diabetologists were predominantly PPG, concern about hypoglycemia, diabetes complications, and adherence to diet and exercise. For metformin, it was age, body mass index (BMI), insulin resistance, renal and liver function, and economic status of the patients.

CONCLUSION

DPP-4 inhibitors, followed by metformin, were the most frequently prescribed OADGs in combination with insulin in a real-world setting in Japan. The diabetologists considered more drug characteristics for DPP-4 inhibitor or metformin-insulin combinations. The treatment factors and patient characteristics for the choice of DPP-4 inhibitors and metformin were comparable across different insulin types.

FUNDING

Novartis Pharma K.K.

Factors Influencing the Prescribing Preferences of Physicians for Drug-Naive Patients with Type 2 Diabetes Mellitus in the Real-World Setting in Japan: Insight from a Web Survey

INTRODUCTION

The Japanese guidelines for type 2 diabetes mellitus (T2DM) emphasize individualization of treatment based on patient need and encourage physicians to select an appropriate oral antidiabetes drug (OAD). However, limited evidence is available on the factors influencing the selection by physicians (diabetes specialists and nonspecialists) of the first-line OAD to treat drug-naive patients with T2DM. A survey was designed to explore the treatment factors and patient characteristics that influence physicians when they choose an initial OAD to prescribe to a drug-naive patient with T2DM in a real-world setting in Japan.

METHODS

The 25-min web-based online survey consisted of simple and focused multiple-choice questions, and was circulated to physicians across eight selected regions in Japan. The primary endpoints were the proportions of physicians who considered particular treatment factors and patient characteristics when selecting the appropriate treatment for drug-naive T2DM patients.

RESULTS

A total of 491 physicians participated in the survey. Dipeptidyl peptidase-4 inhibitors (DPP-4is) were the most-preferred first-line OADs, followed by metformin, of both specialists (69% vs. 60%) and nonspecialists (73% vs. 47%). The most influential factors when a DPP-4i was selected were found to be glycated hemoglobin (HbA1c), postprandial glucose (PPG)-lowering effect, and a low risk of hypoglycemia, which were considered by > 80% of physicians, whereas the key factors when metformin was selected were improvement in insulin resistance, low cost, low risk of hypoglycemia, and PPG- and HbA1c-lowering effects, which were considered by > 85% of physicians. Regression analysis revealed that the dominant reason for choosing DPP-4is over metformin was their ease of use in patients with renal impairment, whereas the dominant reasons for choosing metformin over DPP-4is were improvement in insulin resistance and low cost. The key patient characteristics driving the choice of DPP-4is or metformin as the first-line OAD by physicians were similar to those that influenced the treatment intensification decision (DPP-4is: PPG and renal function; metformin: age, BMI, insulin resistance, and renal function).

CONCLUSION

In Japan, DPP-4is are the preferred first-line OADs, followed by metformin. The key treatment factors and patient characteristics considered when selecting DPP-4is or metformin are similar for both specialists and nonspecialists. These results may prompt further discussion of the differences in T2DM treatment between Japan and other counties.

FUNDING

Novartis.

Initiating Titratable Fixed-Ratio Combinations of Basal Insulin Analogs and Glucagon-Like Peptide-1 Receptor Agonists: What You Need to Know

IN BRIEF Titratable fixed-ratio combinations (FRCs) of a basal insulin and a glucagon-like peptide-1 (GLP-1) receptor agonist are new therapeutic options for people with type 2 diabetes. Two FRCs-insulin degludec/liraglutide and insulin glargine/lixisenatide-have been approved for use in the United States. The two components in these FRCs target different aspects of diabetes pathophysiology, working in a complementary manner to decrease blood glucose while mitigating the side effects associated with each component (hypoglycemia and weight gain with insulin and gastrointestinal side effects with GLP-1 receptor agonists). This article reviews these products and key considerations for their use.

Initiating therapy in patients newly diagnosed with type 2 diabetes: Combination therapy vs a stepwise approach

There is clear evidence that achieving glycaemic targets reduces the risk of developing complications as a result of type 2 diabetes (T2D). Many patients, however, continue to have suboptimal glycaemic control because of issues that include unclear advice on how to achieve these targets as well as clinical inertia. The two management approaches recommended for patients newly diagnosed with T2D are stepwise and combination therapy, each of which has advantages and disadvantages. Stepwise therapy may result in good patient adherence and allow greater individualization of therapy, and minimization of side effects and cost, and so may be appropriate for patients who are closer to goal. Stepwise therapy, however, may also lead to frequent delays in achieving glycaemic goals and longer exposure to hyperglycaemia. Combination therapy, which is now emerging as an important therapy option, has a number of potential advantages over stepwise therapy, including reduction in clinical inertia and earlier and more frequent achievement of glycated haemoglobin goals by targeting multiple pathogenic mechanisms simultaneously, which may more effectively delay disease progression. Compared with stepwise therapy, the disadvantages of combination therapy include reduced patient adherence resulting from complex, multi-drug regimens, difficulty determining the cause of poor efficacy and/or side effects, patient refusal to accept disease, and higher cost. Fixed-dose and fixed-ratio combinations are novel therapeutic approaches which may help address several issues of treatment complexity and patient burden associated with combination therapy comprising individual drugs. The choice of which drugs to administer and the decision to use stepwise vs combination therapy, however, should always be made on an individualized basis.

Conducting a Discrete-Choice Experiment Study Following Recommendations for Good Research Practices: An Application for Eliciting Patient Preferences for Diabetes Treatments

OBJECTIVES

To consolidate and illustrate good research practices in health care to the application and reporting of a study measuring patient preferences for type 2 diabetes mellitus medications, given recent methodological advances in stated-preference methods.

METHODS

The International Society for Pharmacoeconomics and Outcomes Research good research practices and other recommendations were used to conduct a discrete-choice experiment. Members of a US online panel with type 2 diabetes mellitus completed a Web-enabled, self-administered survey that elicited choices between treatment pairs with six attributes at three possible levels each. A D-efficient experimental design blocked 48 choice tasks into three 16-task surveys. Preference estimates were obtained using mixed logit estimation and were used to calculate choice probabilities.

RESULTS

A total of 552 participants (51% males) completed the survey. Avoiding 90 minutes of nausea was valued the highest (mean -10.00; 95% confidence interval [CI] -10.53 to -9.47). Participants wanted to avoid low blood glucose during the day and/or night (mean -3.87; 95% CI -4.32 to -3.42) or one pill and one injection per day (mean -7.04; 95% CI -7.63 to -6.45). Participants preferred stable blood glucose 6 d/wk (mean 4.63; 95% CI 4.15 to 5.12) and a 1% decrease in glycated hemoglobin (mean 5.74; 95% CI 5.22 to 6.25). If cost increased by $1, the probability that a treatment profile would be chosen decreased by 1%.

CONCLUSIONS

These results are consistent with the idea that people have strong preferences for immediate consequences of medication. Despite efforts to produce recommendations, ambiguity surrounding good practices remains and various judgments need to be made when conducting stated-preference studies. To ensure transparency, these judgments should be described and justified.

Effectiveness of Vildagliptin in Clinical Practice: Pooled Analysis of Three Korean Observational Studies (the VICTORY Study)

The present observational study aimed to evaluate the clinical effectiveness of vildagliptin with metformin in Korean patients with type 2 diabetes mellitus (T2DM). Data were pooled from the vildagliptin postmarketing survey (PMS), the vildagliptin/metformin fixed drug combination (DC) PMS, and a retrospective observational study of vildagliptin/metformin (fixed DC or free DC). The effectiveness endpoint was the proportion of patients who achieved a glycemic target (HbA1c) of ≤7.0% at 24 weeks. In total, 4303 patients were included in the analysis; of these, 2087 patients were eligible. The mean patient age was 56.99 ± 11.25 years. Overall, 58.94% patients achieved an HbA1c target of ≤7.0% at 24 weeks. The glycemic target achievement rate was significantly greater in patients with baseline HbA1c < 7.5% versus ≥7.5% (84.64% versus 43.97%), receiving care at the hospital versus clinic (67.95% versus 52.33%), and receiving vildagliptin/metformin fixed DC versus free DC (70.69% versus 55.42%). Multivariate logistic regression analysis indicated that disease duration (P < 0.0001), baseline HbA1c (P < 0.0001), and DC type (P = 0.0103) had significant effects on drug effectiveness. Vildagliptin plus metformin appeared as an effective treatment option for patients with T2DM in clinical practice settings in Korea.

Supplementing Conventional Treatment with Pycnogenol® May Improve Hepatitis C Virus-Associated Type 2 Diabetes: A Mini Review

Hepatitis C virus (HCV) infection and type 2 diabetes mellitus (T2DM) present a significant health burden, with increasing complications and mortality rates worldwide. Pycnogenol® (PYC), a natural product, possesses antidiabetic and antiviral properties that may improve HCV-associated T2DM. In this review, we present previously published data on the effectiveness of PYC against HCV replication and T2DM. We believe that supplementing conventional treatment with PYC may improve the current HCV therapy, attenuate HCV-associated T2DM, and reduce the risk of complications such as cirrhosis or hepatocellular carcinoma and cardiovascular disease.