Hydroxychloroquine in diabetes and dyslipidaemia: primum non nocere

Efficacy and safety of hydroxychloroquine for managing glycemia in type-2 diabetes: A systematic review and meta-analysis

Aims:

No Cochrane meta-analysis with grading of evidence is available on use of hydroxychloroquine (HCQ) in type-2 diabetes (T2DM). This meta-analysis evaluated the efficacy and safety of HCQ in T2DM.

Methods:

Electronic databases were searched using a Boolean search strategy: ((hydroxychloroquine) OR (chloroquine*)) AND ((diabetes) OR (“diabetes mellitus”) OR (glycemia) OR (glucose) OR (insulin)) for studies evaluating hydroxychloroquine for glycemic control in T2DM. The primary outcome was a change in glycated haemoglobin (HbA1c). The secondary outcomes were changes in other glycemic/lipid parameters and adverse effects.

Results:

Data from 11 randomized controlled trials (RCTs) (3 having placebo as controls [passive controls] and 8 having anti-diabetes medications as controls [active controls]) involving 2,723 patients having a median follow-up of 24 weeks were analyzed. About 54.54% of the RCTs were of poor quality as evaluated by the Jadad scale. The performance bias and detection bias were at high risk in 63.64% of the RCTs. The HbA1c reduction with HCQ was marginally better compared to the active (mean differences [MD]-0.17% [95%, CI:-0.30–-0.04;P=0.009;I²=89%; very low certainty of evidence, VLCE]), and passive (MD-1.35% [95%CI:-2.10–-0.59;P=0.005;I²=74%]) controls. A reduction in fasting glucose (MD-16.63mg/dL[95%, CI: -25.99 – -7.28mg/dL;P<0.001;I²=97%;VLCE]) and post-prandial glucose [MD -8.41mg/dL (95%CI: -14.71 – -2.12mg/dL;P=0.009;I²=87%;VLCE]), appeared better with HCQ compared to active controls. The total adverse events (risk ratio [RR]0.93 [95% CI:0.68–1.28]; P=0.65;I²=66%) were not different with HCQ compared to the controls.

Conclusion:

The routine use of HCQ in T2DM cannot be recommended based on the current evidence.

Treatment outcomes of graded dose of empagliflozin in type-2 diabetes: A real world study

Background:

Costs are important cause of therapeutic noncompliance in type-2 diabetes mellitus (T2DM). Half-tablet empagliflozin (EMPA)-25 mg has lowest monthly cost among all EMPA preparations; data is unavailable on efficacy of half EMPA-25. This study compared real world weight loss and glycaemic outcomes of 10 mg versus 12.5 mg versus 25 mg of EMPA.

Methods:

Data, retrospectively captured from records of 2 different centresfor patients > 35 years-age having T2DM on EMPA as part of standard pharmacotherapy for T2DM, having > 6 months follow-up data available was analysed. Patients were in 3-groups depending on EMPA dosage: Group 1 on EMPA 10 mg/day (1-tablet EMPA-10), Group-2 on EMPA 12.5 mg/day (half-tablet EMPA-25), and Group 3 on EMPA 25 mg/day (1-tablet EMPA-25). Primary endpoints were glycaemic efficacy and weight-loss.

Results:

Of 3601 records screened, data from 599 patients (184, 239 and 176 in Group-1, 2 and 3 respectively) was analysed. All 3 groups were comparable with regards to sex, blood pressure, haemoglobin, renal function, medications use. Group-3 were significantly older, had longest diabetes duration, highest HbA1c and lowest body mass index. Glycaemic efficacy was comparable among groups (ΔHbA1c Groups 1-3: −0.9 (−1.9 – 0.0), −1.0 (−1.8 – 0.5) and − 1.0 (−1.5 – 0.22], respectively; P = 0.363). Patients on EMPA 12.5 or 25 mg/d had significantly higher total (−1.4 [−3.0 –0.2] vs. −0.3 [−2.4 – 1.32] kg; P = 0.028) and percent weight-loss (−1.75% [−4.15 – 0.26] vs. −0.44% [−3.11 – 1.39]; P = 0.039), and significantly higherfraction achieving HbA1c < 5.7% (12% vs. 0; P = 0.021), compared to EMPA-10.

Conclusion:

Half EMPA-25 is the most cost effective way of using EMPA in clinical practice.

Short-term Hydroxychloroquine in COVID-19 Infection in People With or Without Metabolic Syndrome - Clearing Safety Issues and Good Clinical Practice

Hydroxychloroquine has been used in rheumatology for decades. This review highlights the mechanistic, clinical and safety data with regards to hydroxychloroquine use in novel coronavirus disease (COVID-19) in people with or without metabolic syndrome. PubMed and Medline were searched for articles published from January 1970 to March 2020 using the terms 'COVID-19', 'corona-virus 2019', 'hydroxychloroquine', 'hypertension', 'diabetes', 'cardiac disease', 'retina' and 'kidney disease'. Hypertension, diabetes and cardiovascular disease are the three most common comorbidities in people with COVID-19, meaning that such people have greater morbidity and mortality. Mechanistically, hydroxychloroquine inhibits SARS-CoV-2 virus uptake into cells by inhibiting angiotensin-converting enzyme 2 glycosylation. This inhibits lysosome activation and the associated cytokine storm, thus reducing the risk of acute respiratory distress syndrome and multiple organ dysfunction syndrome, which is the primary cause of death. Small, in-human studies have shown hydroxychloroquine to improve outcomes in COVID-19, either alone or in combination with azathioprine and other antiviral medications. Retina safety is not an issue with short term use of hydroxychloroquine in COVID-19. Dose reduction is warranted when glomerular filtration rate is <50 mL/min. Cardiac monitoring is warranted in people with established cardiac disease, and cardiac rhythm should be closely monitored when hydroxychloroquine is used with azithromycin, lopinavir, ritonavir or remdesivir. Anti-diabetes medication doses may need to be reduced during treatment with hydroxychloroquine. While we await data from large, in-human trials, short-term use of hydroxychloroquine in COVID-19 is justified, as this molecule has stood the test of time with regards to use in humans for other indications.

Antihyperglycemic properties of hydroxychloroquine in patients with diabetes: Risks and benefits at the time of COVID-19 pandemic

The antimalarial drug hydroxychloroquine (HCQ) has long been used as a disease-modifying antirheumatic drug for the treatment of several inflammatory rheumatic diseases. Over the last three decades, various studies have shown that HCQ also plays a role in the regulation of glucose homeostasis. Although the mechanisms of action underlying the glucose-lowering properties of HCQ are still not entirely clear, evidence suggests that this drug may exert multifaceted effects on glucose regulation, including improvement of insulin sensitivity, increase of insulin secretion, reduction of hepatic insulin clearance, and reduction of systemic inflammation. Preliminary studies have shown the safety and efficacy of HCQ (at a dose ranging from 400 to 600 mg/day) in patients with type 2 diabetes over a short-term period. In 2014, HCQ has been approved in India as an add-on hypoglycemic agent for patients with uncontrolled type 2 diabetes. However, large randomized controlled trials are needed to establish the safety and efficacy profile of HCQ in patients with type 2 diabetes over a long-term period. With regard to the COVID-19 pandemic, several medications (including HCQ) have been used as off-label drugs because of the lack of proven effective therapies. However, emerging evidence shows limited benefit from HCQ use in COVID-19 in general. The aim of this manuscript is to comprehensively summarize the current knowledge on the antihyperglycemic properties of HCQ and to critically evaluate the potential risks and benefits related to HCQ use in patients with diabetes, even in light of the current pandemic scenario.