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Islam L, Jose D, Alkhalifah M, Blaibel D, Chandrabalan V, Pappachan JM. Comparative efficacy of sodium glucose cotransporter-2 inhibitors in the management of type 2 diabetes mellitus: A real-world experience. World J Diabetes 2024; 15:463-474. [PMID: 38591092 PMCID: PMC10999032 DOI: 10.4239/wjd.v15.i3.463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/02/2024] [Accepted: 02/18/2024] [Indexed: 03/15/2024] Open
Abstract
BACKGROUND Sodium glucose cotransporter-2 inhibitors (SGLT-2i) are a class of drugs with modest antidiabetic efficacy, weight loss effect, and cardiovascular benefits as proven by multiple randomised controlled trials (RCTs). However, real-world data on the comparative efficacy and safety of individual SGLT-2i medications is sparse. AIM To study the comparative efficacy and safety of SGLT-2i using real-world clinical data. METHODS We evaluated the comparative efficacy data of 3 SGLT-2i drugs (dapagliflozin, canagliflozin, and empagliflozin) used for treating patients with type 2 diabetes mellitus. Data on the reduction of glycated hemoglobin (HbA1c), body weight, blood pressure (BP), urine albumin creatinine ratio (ACR), and adverse effects were recorded retrospectively. RESULTS Data from 467 patients with a median age of 64 (14.8) years, 294 (62.96%) males and 375 (80.5%) Caucasians were analysed. Median diabetes duration was 16.0 (9.0) years, and the duration of SGLT-2i use was 3.6 (2.1) years. SGLT-2i molecules used were dapagliflozin 10 mg (n = 227; 48.6%), canagliflozin 300 mg (n = 160; 34.3%), and empagliflozin 25 mg (n = 80; 17.1). Baseline median (interquartile range) HbA1c in mmol/mol were: dapagliflozin - 78.0 (25.3), canagliflozin - 80.0 (25.5), and empagliflozin - 75.0 (23.5) respectively. The respective median HbA1c reduction at 12 months and the latest review (just prior to the study) were: 66.5 (22.8) & 69.0 (24.0), 67.0 (16.3) & 66.0 (28.0), and 67.0 (22.5) & 66.5 (25.8) respectively (P < 0.001 for all comparisons from baseline). Significant improvements in body weight (in kilograms) from baseline to study end were noticed with dapagliflozin - 101 (29.5) to 92.2 (25.6), and canagliflozin 100 (28.3) to 95.3 (27.5) only. Significant reductions in median systolic and diastolic BP, from 144 (21) mmHg to 139 (23) mmHg; (P = 0.015), and from 82 (16) mmHg to 78 (19) mmHg; (P < 0.001) respectively were also observed. A significant reduction of microalbuminuria was observed with canagliflozin only [ACR 14.6 (42.6) at baseline to 8.9 (23.7) at the study end; P = 0.043]. Adverse effects of SGLT-2i were as follows: genital thrush and urinary infection - 20 (8.8%) & 17 (7.5%) with dapagliflozin; 9 (5.6%) & 5 (3.13%) with canagliflozin; and 4 (5%) & 4 (5%) with empagliflozin. Diabetic ketoacidosis was observed in 4 (1.8%) with dapagliflozin and 1 (0.63%) with canagliflozin. CONCLUSION Treatment of patients with SGLT-2i is associated with statistically significant reductions in HbA1c, body weight, and better than those reported in RCTs, with low side effect profiles. A review of large-scale real-world data is needed to inform better clinical practice decision making.
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Affiliation(s)
- Lubna Islam
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
| | - Dhanya Jose
- Department of Community Medicine, Goa Medical College, Goa 403202, India
| | - Mohammed Alkhalifah
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
- Department of Family Medicine, King Faisal Specialist Hospital, Riyadh 11564, Saudi Arabia
| | - Dania Blaibel
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
| | - Vishnu Chandrabalan
- Department of Data Science, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
| | - Joseph M Pappachan
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
- Faculty of Science, Manchester Metropolitan University, All Saints Building, Manchester M15 6BH, United Kingdom
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester M13 9PL, United Kingdom
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Deshpande R, Patel R, Regmi MR, Salih M, Kropp R, Al-Bast B, Sheikh MA, Sagalov A, Kulkarni A, Siddique M, Hegde S, Bhattarai M. Safety outcomes of sodium-glucose cotransporter-2 inhibitors in patients with type 2 diabetes and other risk factors for cardiovascular disease: a systematic review and meta-analysis. Cardiovasc Endocrinol Metab 2023; 12:e0284. [PMID: 37180737 PMCID: PMC10171571 DOI: 10.1097/xce.0000000000000284] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 02/22/2023] [Indexed: 05/16/2023]
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2-Is) have emerged as standard therapy for heart failure. We aim to assess the safety of SGLT2-Is in patients with a high risk of cardiovascular disease. Areas covered An electronic database search was conducted for randomized control trials comparing SGLT2-Is to placebo in patients with a high risk of cardiac disease or heart failure. Data were pooled for outcomes using random-effect models. The odds ratio (OR) and 95% confidence interval (CI) were used to compare eight safety outcomes between the two groups. The analysis included ten studies with 71 553 participants, among whom 39 053 received SGLT2-Is; 28 809 were male and 15 655 were female (mean age, 65.2 years). The mean follow-up period was 2.3 years with the range being 0.8-4.2 years. The SGLT2-Is group had a significant reduction in AKI (OR = 0.8;95% CI 0.74-0.90) and serious adverse effects (OR = 0.9; 95% CI 0.83-0.96) as compared to placebo. No difference was found in fracture (OR = 1.1; 95% CI 0.91-1.24), amputation (OR = 1.1; 95% CI 1.00-1.29), hypoglycemia (OR 0.98;95% CI 0.83-1.15), and UTI (OR = 1.1; 95% CI 1.00-1.22). In contrast, DKA (OR = 2.4; 95% CI 1.65-3.60) and volume depletion (OR = 1.2; 95% CI 1.07-1.41) were higher in SGLT2-Is group. Expert opinion/commentary The benefits of SLGT2-Is outweigh the risk of adverse events. They may reduce the risk of AKI but are associated with an increased risk of DKA and volume depletion. Further studies are warranted to monitor a wider range of safety outcomes of SGLT2-Is.
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Affiliation(s)
- Radhika Deshpande
- Department of Internal Medicine, Southern Illinois University School of Medicine
| | - Raj Patel
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Manjari R. Regmi
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Mohsin Salih
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Robert Kropp
- Department of Internal Medicine, Southern Illinois University School of Medicine
| | - Basma Al-Bast
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Muhammad A. Sheikh
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Andrew Sagalov
- Department of Internal Medicine, Southern Illinois University School of Medicine
| | - Abhishek Kulkarni
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Momin Siddique
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Shruti Hegde
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Mukul Bhattarai
- Division of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
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Gautam K, Tripathy R, Meher D, Sahoo JP. Dapagliflozin Versus Vildagliptin as an Adjuvant to Metformin in Patients With Type 2 Diabetes Mellitus: A Randomized, Open-label Study. Cureus 2023; 15:e38200. [PMID: 37252531 PMCID: PMC10224707 DOI: 10.7759/cureus.38200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/31/2023] Open
Abstract
INTRODUCTION The rising burden of diabetes mellitus led to the development of novel drugs like dapagliflozin and vildagliptin. Their efficacies in chronic diabetic patients have been thoroughly studied. However, there is a paucity of comparative studies on these drugs in newly diagnosed diabetic patients. The endpoints of our study were changes in glycated hemoglobin (HbA1c), fasting blood glucose (FBG), and postprandial blood glucose (PPBG) at 24 weeks from baseline. METHODS This randomized, open-label, 24-week study was conducted at Kalinga Institute of Medical Sciences, Bhubaneswar, India, from January 2021 to November 2022. The participants were randomized in a 1:1 ratio to receive tablets of either dapagliflozin 10mg once daily or vildagliptin 50mg once daily as an add-on to metformin 500-2000 mg. The analyses were performed in the per-protocol population. We used R software v. 4.1.1 (R Foundation, Indianapolis, IN) for data analysis. RESULTS 114 (83.8%) of 136 enrolled participants completed this study. The mean age of the study population was 41.08±5.17 years. Additionally, 52 (45.6%) of them were females. The mean changes in HbA1c from baseline were -1.19 (95% CI: -1.36 to -1.03) and -1.28 (95% CI: -1.37 to -1.18) in dapagliflozin and vildagliptin groups, respectively (p=0.21). The median changes in FBG and PPBG in both groups were -38.76, -46.13 (p=0.07), and -51.84, -53.56 (p=0.14), respectively. CONCLUSIONS Reductions in HbA1c, FBG, and PPBG with add-on treatment of vildagliptin were more pronounced than dapagliflozin after a 24-week intervention. However, the differences were not statistically significant.
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Affiliation(s)
- Kumar Gautam
- Pharmacology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | | | - Dayanidhi Meher
- Endocrinology, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
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Siriyotha S, Lukkunaprasit T, Angkananard T, Looareesuwan P, McKay GJ, Attia J, Thakkinstian A. Clinical effectiveness of second-line antihyperglycemic drugs on major adverse cardiovascular events: An emulation of a target trial. Front Endocrinol (Lausanne) 2023; 14:1094221. [PMID: 36793285 PMCID: PMC9922758 DOI: 10.3389/fendo.2023.1094221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/13/2023] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION The cardiovascular benefits of multiple antihyperglycemic drugs as add-on therapies to metformin in the real-practice are unclear. This study aimed to directly compare major adverse cardiovascular events (CVE) associated with these multiple drugs. METHODS An emulation of a target trial was conducted using a retrospective-cohort data of type 2 diabetes mellitus (T2DM) prescribed with second-line drugs on top of metformin, including sodium-glucose cotransporter 2 inhibitors (SGLT2i), dipeptidyl peptidase-4 inhibitors (DPP4i), thiazolidinediones (TZD) and sulfonylureas (SUs). We applied inverse probability weighting and regression adjustment using intention-to-treat (ITT), per-protocol analysis (PPA) and modified ITT. Average treatment effects (ATE) were estimated using SUs as the reference. RESULTS AND DISCUSSION Among 25,498 patients with T2DM, 17,586 (69.0%), 3,261 (12.8%), 4,399 (17.3%), and 252 (1.0%) received SUs, TZD, DPP4i, and SGLT2i. Median follow-up time was 3.56 (1.36-7.00) years. CVE was identified in 963 patients. The ITT and modified ITT approaches showed similar results; the ATE (i.e., the difference of CVE risks) for SGLT2i, TZD, and DPP4i compared to SUs were -0.020(-0.040, -0.0002), -0.010(-0.017, -0.003), and -0.004(-0.010, 0.002), respectively, indicating 2% and 1% significant absolute risk reduction in CVE in SGLT2i and TZD compared to SUs. These corresponding effects were also significant in the PPA with ATEs of -0.045(-0.060, -0.031), -0.015(-0.026, -0.004), and -0.012(-0.020, -0.004). In addition, SGLT2i had 3.3% significant absolute risk reduction in CVE relative to DPP4i. Our study demonstrated benefits of SGLT2i and TZD in reducing CVE in T2DM patients compared to SUs when added to metformin.
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Affiliation(s)
- Sukanya Siriyotha
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thitiya Lukkunaprasit
- Department of Pharmacy Administration, College of Pharmacy, Rangsit University, Pathum Thani, Thailand
| | - Teeranan Angkananard
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakhon Nayok, Thailand
- *Correspondence: Teeranan Angkananard, , ; Panu Looareesuwan,
| | - Panu Looareesuwan
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- *Correspondence: Teeranan Angkananard, , ; Panu Looareesuwan,
| | - Gareth J. McKay
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, United Kingdom
| | - John Attia
- Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, and Hunter Medical Research Institute, New Lambton, NSW, Australia
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Zaawari A, Sahar AN. Sodium-glucose Co-transporter-2 inhibitors (SGLT2I): A class of drugs with promising cardiorenal protective effects beyond glycemic control. Ann Med Surg (Lond) 2022; 81:104536. [PMID: 36147162 PMCID: PMC9486725 DOI: 10.1016/j.amsu.2022.104536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/26/2022] [Accepted: 08/27/2022] [Indexed: 11/29/2022] Open
Abstract
Diabetes Mellitus is always associated with both microvascular and macrovascular complications. Cardiovascular and renal complications are the leading cause of morbidity and mortality in these populations. Sodium-glucose co-transporter 2 inhibitors are a new class of antidiabetic drugs. These drugs have shown promising cardiovascular and renal protective mechanisms and resulted in decreased mortality and hospitalization. The benefits of these drugs are expected to expand to non-diabetic patients and provide improved cardiovascular and renal outcomes. In this brief review, we outline the potential cardiorenal benefits of these drugs and their future implication to improve glycemic, cardiovascular, and renal outcomes.
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Lasalvia P, Gil-Rojas Y, García Á. Cost-effectiveness of dapagliflozin compared to DPP-4 inhibitors as combination therapy with metformin in the treatment of type 2 diabetes mellitus without established cardiovascular disease in Colombia. Expert Rev Pharmacoecon Outcomes Res 2022; 22:955-964. [PMID: 35259045 DOI: 10.1080/14737167.2022.2044310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION SGLT2 inhibitors or DPP-4 inhibitors are among the preferred options in patients with type 2 diabetes mellitus (T2DM) without established cardiovascular disease. OBJECTIVE To evaluate the incremental cost-effectiveness of dapagliflozin versus DPP-4 inhibitors as a complement to metformin in the treatment ofT2D, from the perspective of the Colombian health system. METHODS The Cardiff model was used to estimate the incremental cost-effectiveness ratio (ICER) of dapagliflozin plus metformin compared to DPP-4 inhibitors plus metformin in adults with T2DM who did not respond adequately to metformin monotherapy. We estimated the incidence of micro- and macrovascular complications from risk equations incorporating the effect of treatment. The time horizon for analysis was 5 years and a discount rate of 5% was applied, for both costs and outcomes. The costs were expressed in 2020 USD (1 USD = $3,693.36 COP). RESULTS Dapagliflozin in association with metformin resulted in a higher number of quality-adjusted life years (QALYs) compared to the intervention. The ICER was US$1,964.80 per QALY gained. CONCLUSION From the point of view of Colombian healthcare system, the combination of dapagliflozin with metformin is a cost-effective option compared to DPP-4 + metformin inhibitors in the treatment of T2D without established cardiovascular disease.
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Affiliation(s)
| | | | - Ángel García
- Cardiology Unit, San Ignacio University Hospital. Pontificia Universidad Javeriana, Bogotá, Colombia
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The SGLT-2 Inhibitors in Personalized Therapy of Diabetes Mellitus Patients. J Pers Med 2021; 11:jpm11121249. [PMID: 34945721 PMCID: PMC8708213 DOI: 10.3390/jpm11121249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 12/13/2022] Open
Abstract
Diabetes mellitus (DM) represents a major public health problem, with yearly increasing prevalence. DM is considered a progressive vascular disease that develops macro and microvascular complications, with a great impact on the quality of life of diabetic patients. Over time, DM has become one of the most studied diseases; indeed, finding new pharmacological ways to control it is the main purpose of the research involved in this issue. Sodium–glucose cotransporter 2 inhibitors (SGLT-2i) are a modern drug class of glucose-lowering agents, whose use in DM patients has increased in the past few years. Besides the positive outcomes regarding glycemic control and cardiovascular protection in DM patients, SGLT-2i have also been associated with metabolic benefits, blood pressure reduction, and improved kidney function. The recent perception and understanding of SGLT-2i pathophysiological pathways place this class of drugs towards a particularized patient-centered approach, moving away from the well-known glycemic control strategy. SGLT-2i have been shown not only to reduce death from cardiovascular causes, but also to reduce the risk of stroke and heart failure hospitalization. This article aims to review and highlight the existing literature on the effects of SGLT-2i, emphasizing their role as oral antihyperglycemic agents in type 2 DM, with important cardiovascular and metabolic benefits.
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Kim K, Choi SH. Cardiovascular Safety of SGLT2 Inhibitors Compared to DPP4 Inhibitors and Sulfonylureas as the Second-Line of Therapy in T2DM Using Large, Real-World Clinical Data in Korea. Diabetes Metab J 2021; 45:502-504. [PMID: 34352987 PMCID: PMC8369211 DOI: 10.4093/dmj.2021.0158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Kyuho Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sung Hee Choi
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Corresponding author: Sung Hee Choi https://orcid.org/0000-0003-0740-8116 Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea E-mail:
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Bhavyasri K, Surekha T, Begum S, Sumakanth M. RP-HPLC Method for Dapagliflozin and Metformin HCL in Bulk and Combined Formulation. ARCHIVES OF PHARMACY PRACTICE 2021. [DOI: 10.51847/czxl0wyryr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Morieri ML, Consoli A, Sesti G, Purrello F, Avogaro A, Fadini GP. Comparative effectiveness of dapagliflozin vs DPP-4 inhibitors on a composite endpoint of HbA1c, body weight and blood pressure reduction in the real world. Diabetes Metab Res Rev 2021; 37:e3353. [PMID: 32453482 DOI: 10.1002/dmrr.3353] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/06/2020] [Accepted: 05/22/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Treatment of type 2 diabetes (T2D) should aim at preventing or delaying complications through the control of glycaemia and cardiovascular risk factors. We herein compared the SGLT-2 inhibitor dapagliflozin vs DPP-4 inhibitors (DPP-4i) on a composite endpoint of glycaemic and extraglycaemic effectiveness. METHODS This was a multicentre, retrospective real-world study conducted at 56 outpatient clinics in Italy. We collected data on patients newly started on dapagliflozin or DPP-4i in 2015-2017. The primary endpoint was the proportion of patients attaining a simultaneous reduction of HbA1c ≥0.5%, body weight ≥2 kg, systolic blood pressure (SBP) ≥2 mmHg. Confounding by indication was addressed by propensity score matching (PSM) or multivariable adjustment (MVA). RESULTS Patients initiating dapagliflozin (n = 2091) or DPP-4i (n = 2144) differed for most clinical characteristics. After PSM, two well-balanced groups of 1149 patients each were compared. The primary endpoint was reached in a greater proportion of patients who received dapagliflozin (17.6%) compared to DPP-4i (11.7%), with a relative risk of 1.50 (1.21-1.86; P < .001). Similar results were obtained in the as-treated and intention-to-treat datasets or using MVA in place of PSM. The beneficial effect of dapagliflozin was mainly due to its greater effectiveness on body weight and, to a lesser extent, on SBP. The change in HbA1c did not differ between groups. CONCLUSIONS T2D patients initiating the SGLT2i dapagliflozin had a greater probability of attaining a composite endpoint of clinically relevant reductions in HbA1c, body weight and SBP, compared to similar patients initiating a DPP-4i in the same period and healthcare setting.
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Affiliation(s)
| | | | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova, Italy
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Portela-Romero M, Cinza-Sanjurjo S, Rey-Aldana D, González-Juanatey JR. [Analysis on the impact of the introduction of a quality management plan of the diabetes care process in a Health Area of Galicia (Spain)]. J Healthc Qual Res 2020; 35:305-311. [PMID: 32972902 DOI: 10.1016/j.jhqr.2020.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/18/2020] [Accepted: 04/26/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To analyse the impact of a management plan for the diabetes process on the level of control of HbA1c and the rate of hypoglycaemia. MATERIAL AND METHODS The Health Area had a catchment population of 446,603. An anti-diabetic drug prescription (29,705 patients) was used to select diabetic patients. The variables recorded were: percentage of patients with HbA1c <8% and the hypoglycaemia rate before and after implementation of the quality program. RESULTS The prevalence of diabetes was 11.8%, with 71.3% of them receiving some pharmacological treatment. In the year 2016, in the Integrated Health Area of Santiago de Compostela (Spain), 59.6% (95% CI: 57.9% -61.2%) of the patients had an HbA1c of less than 8%. After the implementation of the quality program, there was an increase in the number of controlled patients, reaching 63.6% (IRQ: 16.0%) in 2017, and 63.8% (95% CI: 62.5% - 65.2%) in 2018. The annual rate of hypoglycaemia increased non-significantly from 2.8 (95% CI: 2.22-3.35) in 2016, to 2.94 (95% CI: 2.35-2.35) in 2017 (P=.083), and 3.0 (95% CI: 2.44-3.56) in 2018 (P=.399). CONCLUSIONS The implementation of the diabetes process management program enabled the level of control of HbA1c to be improved, as well as increase the percentage of patients who undergo regular check-ups, without increasing hypoglycaemia.
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Affiliation(s)
- M Portela-Romero
- Subdirección de Procesos Asistenciales (Área Médica), Área Sanitaria Integrada de Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - S Cinza-Sanjurjo
- CS Porto do Son, Área Sanitaria Integrada de Santiago de Compostela, Porto de Son, A Coruña, España.
| | - D Rey-Aldana
- CS A Estrada, Área Sanitaria Integrada de Santiago de Compostela, A Estrada, Pontevedra, España
| | - J R González-Juanatey
- Jefe Servicio Cardiología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España
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Frias JP, Gonzalez‐Galvez G, Johnsson E, Maaske J, Testa MA, Simonson DC, Dronamraju N, Garcia‐Sanchez R, Peters AL. Efficacy and safety of dual add-on therapy with dapagliflozin plus saxagliptin versus glimepiride in patients with poorly controlled type 2 diabetes on a stable dose of metformin: Results from a 52-week, randomized, active-controlled trial. Diabetes Obes Metab 2020; 22:1083-1093. [PMID: 32052516 PMCID: PMC7317565 DOI: 10.1111/dom.13997] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/30/2020] [Accepted: 02/09/2020] [Indexed: 01/14/2023]
Abstract
AIMS To evaluate the efficacy and safety of dapagliflozin (DAPA) + saxagliptin (SAXA) compared with glimepiride (GLIM) in patients with type 2 diabetes who were inadequately controlled [glycated haemoglobin (HbA1c) 7.5-10.5% (58-91 mmol/mol)] on metformin monotherapy. MATERIALS AND METHODS This 52-week, multicentre, double-blind, active-controlled study (NCT02419612) randomized (1:1) patients on metformin to add-on DAPA 10 mg + SAXA 5 mg (n = 227) or GLIM 1-6 mg (titrated; n = 217). The primary efficacy endpoint was change in HbA1c from baseline to week 52. RESULTS Baseline mean ± standard deviation of age, duration of diabetes and HbA1c were 56.1 ± 9.7 years, 7.8 ± 6.4 years and 8.5% ± 0.8% (69 ± 9.0 mmol/mol), respectively. Adjusted mean change from baseline in HbA1c was -1.35% (-14.8 mmol/mol) with DAPA + SAXA versus -0.98% (-10.7 mmol/mol) with GLIM (P <0.001). Changes from baseline in body weight and systolic blood pressure were -3.1 kg and -2.6 mmHg with DAPA + SAXA versus +1.0 kg (P <0.001) and +1.0 mmHg (P = 0.007) with GLIM. More patients achieved HbA1c <7.0% (53 mmol/mol) (44.3% vs. 34.3%; P = 0.044), and fewer patients required treatment intensification (1.3% vs. 8.8%; P = 0.002) with DAPA + SAXA than with GLIM. CONCLUSIONS Compared with GLIM, concurrent addition of DAPA + SAXA significantly improved glycaemic control, body weight and other metabolic parameters in patients inadequately controlled on metformin. Trial: NCT02419612, ClinicalTrials.gov.
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Affiliation(s)
| | | | - Eva Johnsson
- BioPharmaceuticals R&D, AstraZenecaGothenburgSweden
| | - Jill Maaske
- BioPharmaceuticals R&D, AstraZenecaGaithersburgMaryland
| | - Marcia A. Testa
- Harvard T.H. Chan School of Public HealthBostonMassachusetts
| | - Donald C. Simonson
- Division of Endocrinology, Diabetes and HypertensionBrigham and Women's HospitalBostonMassachusetts
- Harvard Medical SchoolBostonMassachusetts
| | | | | | - Anne L. Peters
- Keck School of Medicine of the University of Southern CaliforniaLos Angeles, California
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13
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Elkind-Hirsch KE, Seidemann E, Harris R. A randomized trial of dapagliflozin and metformin, alone and combined, in overweight women after gestational diabetes mellitus. Am J Obstet Gynecol MFM 2020; 2:100139. [PMID: 33345876 DOI: 10.1016/j.ajogmf.2020.100139] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/01/2020] [Accepted: 05/06/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Women with a history of gestational diabetes mellitus are at a substantially increased risk of gestational diabetes mellitus recurrence and type 2 diabetes. Weight gain, particularly increased central adiposity after delivery, is strongly associated with deterioration of pancreatic beta cell compensation for insulin resistance. Weight management after gestational diabetes mellitus could have a significant benefit in these women who are at a high risk of developing type 2 diabetes. OBJECTIVE This study aimed to evaluate the treatment efficacy of dapagliflozin and metformin, alone and in combination, on body weight and anthropometric, cardiovascular, and metabolic parameters in overweight women with a recent history of gestational diabetes mellitus. STUDY DESIGN This was a prospective, single-blind, randomized, outpatient clinical trial with 3 parallel treatment groups. Overweight or obese (body mass index>25) females (n=66; ≥18-45 years) with gestational diabetes mellitus in pregnancy in the past 12 months were randomized in a single-blind manner to dapagliflozin, metformin, or dapagliflozin-metformin for 24 weeks. Body weight, height, body mass index, waist circumference, waist-to-height ratio, and blood pressure were determined at baseline and trial completion. Oral glucose tolerance tests were performed at baseline and 24 weeks to assess glycemia and mean blood glucose and calculate insulin sensitivity and secretion measures. Plasma lipid fractions, thyroid-stimulating hormone, and liver enzymes were also assessed in the fasting sample at the beginning and completion of the study trial. RESULTS The study was completed by 49 participants (74%). Significant reduction of weight, waist circumference, and waist-to-height ratio and improved glycemia and insulin sensitivity index derived from oral glucose tolerance test were found with dapagliflozin-metformin vs metformin monotherapy. Both dapagliflozin and dapagliflozin-metformin therapy were superior to metformin in increasing high-density lipoprotein levels, reducing triglyceride concentrations, lowering the triglyceride-to-high-density lipoprotein cholesterol ratio, and improving glucose excursion after an oral glucose tolerance test. The early insulin response to a glucose challenge significantly improved with only dapagliflozin-metformin compared with single-drug treatments. CONCLUSION This is the first report comparing the efficacy of a sodium-glucose cotransporter 2 inhibitor alone and in combination with metformin in this patient population. We found that combination dapagliflozin-metformin treatment over a 24-week period had a greater positive effect on body weight, waist circumference, and glycemic, cardiovascular, and metabolic parameters than metformin monotherapy in overweight or obese at-risk women with a recent history of gestational diabetes mellitus.
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Affiliation(s)
| | - Ericka Seidemann
- Woman's Metabolic Clinic and Research Center, Woman's Hospital, Baton Rouge, LA
| | - Renee Harris
- Woman's Metabolic Clinic and Research Center, Woman's Hospital, Baton Rouge, LA
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14
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Morillas C, Escalada J, Palomares R, Bellido D, Gómez-Peralta F, Pérez A. Treatment of Type 2 Diabetes by Patient Profile in the Clinical Practice of Endocrinology in Spain: Delphi Study Results from the Think Twice Program. Diabetes Ther 2019; 10:1893-1907. [PMID: 31359366 PMCID: PMC6778580 DOI: 10.1007/s13300-019-0671-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The aim of this Delphi study is to unveil the management of patients with type 2 diabetes (T2D) and different levels of complexity in the clinical practice in Spain. METHODS Based on the common management practices of T2D profiles reported by Spanish endocrinologists, a Delphi questionnaire of 55 statements was developed and responded to by a national panel (n = 101). RESULTS A consensus was reached for 30 of the 55 statements. Regarding overweight patients inadequately controlled with metformin, treatment with a sodium-glucose transport protein 2 inhibitor (SGLT2-I) is preferred over treatment with a dipeptidyl peptidase-4 inhibitor (DPP4-I). If the patient is already being treated with a DPP4-I, an SGLT2-I is added on to the treatment regimen rather than replacing the DPP4-I. Conversely, if the treatment regimen includes a sulfonylurea, it is usually replaced by other antihyperglycemic agents. Current treatment trends in uncontrolled obese patients include the addition of an SGLT2-I or a glucagon-like peptide-1 receptor agonist (GLP1-RA) to background therapy. When the glycated hemoglobin target is not reached, triple therapy with metformin + GLP1-RA + SGLT2-I is initiated. Although SGLT2-Is are the treatment of choice in patients with T2D and heart failure or uncontrolled hypertension, no consensus was reached regarding the preferential use of SGLT2-Is or GLP1-RAs in patients with established cardiovascular disease. CONCLUSION Consensus has been reached for a variety of statements regarding the management of several T2D profiles. Achieving a more homogeneous management of complex patients with T2D may require further evidence and a better understanding of the key drivers for treatment choice. FUNDING Logistic support was provided by ESTEVE Pharmaceuticals S.A Spain.
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Affiliation(s)
| | | | | | - Diego Bellido
- Hospital Arquitecto Marcide, Complejo Hospitalario Universitario de Ferrol [CHUF], El Ferrol, Spain
| | | | - Antonio Pérez
- Hospital de la Santa Creu i Sant Pau, CIBERDEM, c/de Sant Quintí, Barcelona, Spain
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15
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Zozaya N, Capel M, Simón S, Soto-González A. A systematic review of economic evaluations in non-insulin antidiabetic treatments for patients with type 2 diabetes mellitus. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2019. [DOI: 10.1177/2284240319876574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The approval of new non-insulin treatments has broadened the therapeutic arsenal, but it has also increased the complexity of choice for the treatment of type 2 diabetes mellitus (DM2). The objective of this study was to systematically review the literature on economic evaluations associated with non-insulin antidiabetic drugs (NIADs) for DM2. We searched in Medline, IBECS, Doyma and SciELO databases for full economic evaluations of NIADs in adults with DM2 applied after the failure of the first line of pharmacological treatment, published between 2010 and 2017, focusing on studies that incorporated quality-adjusted life years (QALYs). The review included a total of 57 studies, in which 134 comparisons were made between NIADs. Under an acceptability threshold of 25,000 euros per QALY gained, iSLGT-2 were preferable to iDPP-4 and sulfonylureas in terms of incremental cost-utility. By contrast, there were no conclusive comparative results for the other two new NIAD groups (GLP-1 and iDPP-4). The heterogeneity of the studies’ methodologies and results hindered our ability to determine under what specific clinical assumptions some NIADs would be more cost-effective than others. Economic evaluations of healthcare should be used as part of the decision-making process, so multifactorial therapeutic management strategies should be established based on the patients’ clinical characteristics and preferences as principal criteria.
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Affiliation(s)
- Néboa Zozaya
- Department of Health Economics, Weber Economía y Salud, Madrid, Spain
- University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | | | | | - Alfonso Soto-González
- Department of Endocrinology and Nutrition, Gerencia de Gestión Integrada de A Coruña, A Coruña, Spain
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16
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Tentolouris A, Vlachakis P, Tzeravini E, Eleftheriadou I, Tentolouris N. SGLT2 Inhibitors: A Review of Their Antidiabetic and Cardioprotective Effects. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E2965. [PMID: 31426529 PMCID: PMC6720282 DOI: 10.3390/ijerph16162965] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/10/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023]
Abstract
Type 2 diabetes mellitus is a chronic metabolic disease associated with high cardiovascular (CV) risk. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are the latest class of antidiabetic medication that inhibit the absorption of glucose from the proximal tubule of the kidney and hence cause glycosuria. Four SGLT2i are currently commercially available in many countries: canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin. SGLT2i reduce glycated hemoglobin by 0.5%-1.0% and have shown favorable effects on body weight, blood pressure, lipid profile, arterial stiffness and endothelial function. More importantly, SGLT2i have demonstrated impressive cardioprotective and renoprotective effects. The main mechanisms underlying their cardioprotective effects have been attributed to improvement in cardiac cell metabolism, improvement in ventricular loading conditions, inhibition of the Na+/H+ exchange in the myocardial cells, alteration in adipokines and cytokines production, as well as reduction of cardiac cells necrosis and cardiac fibrosis. The main adverse events of SGLT2i include urinary tract and genital infections, as well as euglycemic diabetic ketoacidosis. Concerns have also been raised about the association of SGLT2i with lower limb amputations, Fournier gangrene, risk of bone fractures, female breast cancer, male bladder cancer, orthostatic hypotension, and acute kidney injury.
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Affiliation(s)
- Anastasios Tentolouris
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 11527 Athens, Greece
| | - Panayotis Vlachakis
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 11527 Athens, Greece
| | - Evangelia Tzeravini
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 11527 Athens, Greece
| | - Ioanna Eleftheriadou
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 11527 Athens, Greece
| | - Nikolaos Tentolouris
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 11527 Athens, Greece.
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17
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Li J, Fagbote CO, Zhuo M, Hawley CE, Paik JM. Sodium-glucose cotransporter 2 inhibitors for diabetic kidney disease: a primer for deprescribing. Clin Kidney J 2019; 12:620-628. [PMID: 31583087 PMCID: PMC6768299 DOI: 10.1093/ckj/sfz100] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) is a critical global public health problem associated with high morbidity and mortality, poorer quality of life and increased health care expenditures. CKD and its associated comorbidities are one of the most complex clinical constellations to manage. Treatments for CKD and its comorbidities lead to polypharmacy, which exponentiates the morbidity and mortality. Sodium-glucose cotransporter 2 inhibitors (SGLT2is) have shown remarkable benefits in cardiovascular and renal protection in patients with type 2 diabetes mellitus (T2DM). The pleiotropic effects of SGLT2is beyond glycosuria suggest a promising role in reducing polypharmacy in diabetic CKD, but the potential adverse effects of SGLT2is should also be considered. In this review, we present a typical case of a patient with multiple comorbidities seen in a CKD clinic, highlighting the polypharmacy and complexity in the management of proteinuria, hyperkalemia, volume overload, hyperuricemia, hypoglycemia and obesity. We review the cardiovascular and renal protection effects of SGLT2is in the context of clinical trials and current guidelines. We then discuss the roles of SGLT2is in the management of associated comorbidities and review the adverse effects and controversies of SGLT2is. We conclude with a proposal for deprescribing principles when initiating SGLT2is in patients with diabetic CKD.
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Affiliation(s)
- Jiahua Li
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Renal Section, VA Boston Healthcare System, Boston, MA, USA
| | | | - Min Zhuo
- Renal Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Chelsea E Hawley
- Department of Pharmacy, VA Boston Healthcare System, Boston, MA, USA.,New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA
| | - Julie M Paik
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Renal Section, VA Boston Healthcare System, Boston, MA, USA.,New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Boston, MA, USA
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18
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Viswanathan V, Singh KP. Use of Dapagliflozin in the Management of Type 2 Diabetes Mellitus: A Real-World Evidence Study in Indian Patients (FOREFRONT). Diabetes Technol Ther 2019; 21:415-422. [PMID: 31339784 DOI: 10.1089/dia.2019.0052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Dapagliflozin is approved in India based on a controlled clinical study. This study included type 2 diabetes mellitus (T2DM) Indian patients to determine effectiveness of dapagliflozin in the real-world setup. Methods: Data were collected retrospectively and prospectively for 3 months. Primary endpoint was mean change in glycated hemoglobin (HbA1c) from baseline to months 3 and 6. Patients were stratified by baseline HbA1c and body mass index (BMI). Paired t-test or Wilcoxon signed-rank test at 5% level of significance with two-sided 95% confidence intervals analyzed endpoints. Results: Total 98.1% (n = 1941/1978) patients completed the study, majority of them were men (57.5%), <60 years (77.8%). Mean (standard deviation [SD]) HbA1c decreased significantly from baseline (9.11% [1.44]) to month 3 (8.11% [1.22]; Δ = 1.00% [1.01]) and month 6 (7.62% [1.04]; Δ = 1.49% [1.18]), P < 0.001. Per baseline HbA1c stratification, the largest mean (SD) decrease in HbA1c was in patients with baseline HbA1c >10% (1.86% [1.32] at month 3; 2.80% [1.22] at month 6). Decrease in mean body weight was significant from baseline (78.15 kg [13.48]) to month 3 (77.01 kg [13.21]; Δ = 1.14 kg [2.21]) and month 6 (76.16 kg [13.09]; Δ = 1.86 kg [3.04]), P < 0.001, with maximum weight loss in patients with BMI >30 kg/m2 (1.60 kg [2.50] and 2.56 kg [3.50] at months 3 and 6, respectively). Systolic/diastolic blood pressure also improved. Of the 58 (2.9%) patients having ≥1 adverse event (AE), 9 (0.5%) had vulvovaginitis and 4 (0.2%) each had fungal infection and urinary tract infection (UTI). One patient had a serious AE (SAE) of UTI. No patients died or discontinued the study because of AEs or SAEs. Conclusion: Dapagliflozin significantly decreased HbA1c and body weight in Indian T2DM patients. Dapagliflozin was well tolerated and no new safety signals were detected.
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Affiliation(s)
| | - K P Singh
- 2Endocrinologist, Fortis Med Centre, SCO-11, Chandigarh, India
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19
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Moradi-Marjaneh R, Paseban M, Sahebkar A. Natural products with SGLT2 inhibitory activity: Possibilities of application for the treatment of diabetes. Phytother Res 2019; 33:2518-2530. [PMID: 31359514 DOI: 10.1002/ptr.6421] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/15/2019] [Accepted: 05/26/2019] [Indexed: 12/13/2022]
Abstract
Diabetes mellitus currently affects as many as 400 million people worldwide, creating a heavy economic burden and stretching health care resources. A dysfunction of glucose homeostasis underlies the disease. Despite advances in the treatment of diabetes, many patients still suffer from complications and side effects; hence, development of more effective treatments for diabetes is still desirable. SGLT2 is the principle cotransporter involved in glucose reabsorption in the kidney. SGLT2 inhibition reduces glucose reabsorption by the kidney and ameliorates plasma glucose concentration. The interest in natural products that can be used for the inhibition of SGLT2 is growing. The flavonoid phlorizin, which can be isolated from the bark of apple trees, has been used as lead structure due to its inhibitory activity of SGLT1 and SGLT2. Some phlorizin-derived synthetic compounds, including canagliflozin, dapagliflozin, empagliflozin, ipragliflozin, and ertugliflozin, are approved by the food and drug administration to treat type 2 diabetes mellitus (T2DM), whereas others are under clinical trials investigation. In addition, other natural product-derived compounds have been investigated for their ability to improve blood glucose control. The present review summarizes the natural products with SGLT2 inhibitory activity, and the synthetic compounds obtained from them, and discusses their application for the treatment of diabetes.
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Affiliation(s)
| | - Maryam Paseban
- Department of Physiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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20
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New anti-hyperglycaemic agents for type 2 diabetes and their effects on diabetic retinopathy. Eye (Lond) 2019; 33:1842-1851. [PMID: 31227789 DOI: 10.1038/s41433-019-0494-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/19/2019] [Accepted: 05/21/2019] [Indexed: 12/11/2022] Open
Abstract
There has been an increase in the range of non-insulin anti-hyperglycaemic agents used to treat type 2 diabetes. With the globally rising rates of type 2 diabetes and complications such as diabetic retinopathy, it is important for ophthalmologists to be aware of these new agents and their impacts on diabetic retinopathy and diabetic macular oedema. We conducted a review of the literature to determine if there were any beneficial or harmful effects of the currently used anti-hyperglycaemic agents on diabetic retinopathy or diabetic macular oedema. Our review of the current literature found that apart from thiazolidinediones, anti-hyperglycaemic agents have been reported to have beneficial or neutral effects on diabetic eye complications. Thiazolidinediones (pioglitazone is the only one currently available) have been linked to incident or worsening diabetic macular oedema, although the rate is believed to be low. Glucagon-like peptide 1 (GLP1) agonists (incretins) in general are beneficial except semaglutide which is associated with increased rates of diabetic retinopathy complications. These results have implications for selection of anti-hyperglycaemic agents for patients with diabetic retinopathy or macular oedema. Further studies need to be conducted to identify if reported beneficial effects are independent of the impact of glycaemic control. Early worsening of retinopathy with tight glycaemic control should also be noted in interpretation of future studies.
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21
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Madsen KS, Kähler P, Kähler LKA, Madsbad S, Gnesin F, Metzendorf M, Richter B, Hemmingsen B. Metformin and second- or third-generation sulphonylurea combination therapy for adults with type 2 diabetes mellitus. Cochrane Database Syst Rev 2019; 4:CD012368. [PMID: 30998259 PMCID: PMC6472662 DOI: 10.1002/14651858.cd012368.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The number of people with type 2 diabetes mellitus (T2DM) is increasing worldwide. The combination of metformin and sulphonylurea (M+S) is a widely used treatment. Whether M+S shows better or worse effects in comparison with other antidiabetic medications for people with T2DM is still controversial. OBJECTIVES To assess the effects of metformin and sulphonylurea (second- or third-generation) combination therapy for adults with type 2 diabetes mellitus. SEARCH METHODS We updated the search of a recent systematic review from the Agency for Healthcare Research and Quality (AHRQ). The updated search included CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and WHO ICTRP. The date of the last search was March 2018. We searched manufacturers' websites and reference lists of included trials, systematic reviews, meta-analyses and health technology assessment reports. We asked investigators of the included trials for information about additional trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) randomising participants 18 years old or more with T2DM to M+S compared with metformin plus another glucose-lowering intervention or metformin monotherapy with a treatment duration of 52 weeks or more. DATA COLLECTION AND ANALYSIS Two review authors read all abstracts and full-text articles and records, assessed risk of bias and extracted outcome data independently. We used a random-effects model to perform meta-analysis, and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using the GRADE instrument. MAIN RESULTS We included 32 RCTs randomising 28,746 people. Treatment duration ranged between one to four years. We judged none of these trials as low risk of bias for all 'Risk of bias' domains. Most important events per person were all-cause and cardiovascular mortality, serious adverse events (SAE), non-fatal stroke (NFS), non-fatal myocardial infarction (MI) and microvascular complications. Most important comparisons were as follows:Five trials compared M+S (N = 1194) with metformin plus a glucagon-like peptide 1 analogue (N = 1675): all-cause mortality was 11/1057 (1%) versus 11/1537 (0.7%), risk ratio (RR) 1.15 (95% confidence interval (CI) 0.49 to 2.67); 3 trials; 2594 participants; low-certainty evidence; cardiovascular mortality 1/307 (0.3%) versus 1/302 (0.3%), low-certainty evidence; serious adverse events (SAE) 128/1057 (12.1%) versus 194/1537 (12.6%), RR 0.90 (95% CI 0.73 to 1.11); 3 trials; 2594 participants; very low-certainty evidence; non-fatal myocardial infarction (MI) 2/549 (0.4%) versus 6/1026 (0.6%), RR 0.57 (95% CI 0.12 to 2.82); 2 trials; 1575 participants; very low-certainty evidence.Nine trials compared M+S (N = 5414) with metformin plus a dipeptidyl-peptidase 4 inhibitor (N = 6346): all-cause mortality was 33/5387 (0.6%) versus 26/6307 (0.4%), RR 1.32 (95% CI 0.76 to 2.28); 9 trials; 11,694 participants; low-certainty evidence; cardiovascular mortality 11/2989 (0.4%) versus 9/3885 (0.2%), RR 1.54 (95% CI 0.63 to 3.79); 6 trials; 6874 participants; low-certainty evidence; SAE 735/5387 (13.6%) versus 779/6307 (12.4%), RR 1.07 (95% CI 0.97 to 1.18); 9 trials; 11,694 participants; very low-certainty evidence; NFS 14/2098 (0.7%) versus 8/2995 (0.3%), RR 2.21 (95% CI 0.74 to 6.58); 4 trials; 5093 participants; very low-certainty evidence; non-fatal MI 15/2989 (0.5%) versus 13/3885 (0.3%), RR 1.45 (95% CI 0.69 to 3.07); 6 trials; 6874 participants; very low-certainty evidence; one trial in 64 participants reported no microvascular complications were observed (very low-certainty evidence).Eleven trials compared M+S (N = 3626) with metformin plus a thiazolidinedione (N = 3685): all-cause mortality was 123/3300 (3.7%) versus 114/3354 (3.4%), RR 1.09 (95% CI 0.85 to 1.40); 6 trials; 6654 participants; low-certainty evidence; cardiovascular mortality 37/2946 (1.3%) versus 41/2994 (1.4%), RR 0.78 (95% CI 0.36 to 1.67); 4 trials; 5940 participants; low-certainty evidence; SAE 666/3300 (20.2%) versus 671/3354 (20%), RR 1.01 (95% CI 0.93 to 1.11); 6 trials; 6654 participants; very low-certainty evidence; NFS 20/1540 (1.3%) versus 16/1583 (1%), RR 1.29 (95% CI 0.67 to 2.47); P = 0.45; 2 trials; 3123 participants; very low-certainty evidence; non-fatal MI 25/1841 (1.4%) versus 21/1877 (1.1%), RR 1.21 (95% CI 0.68 to 2.14); P = 0.51; 3 trials; 3718 participants; very low-certainty evidence; three trials (3123 participants) reported no microvascular complications (very low-certainty evidence).Three trials compared M+S (N = 462) with metformin plus a glinide (N = 476): one person died in each intervention group (3 trials; 874 participants; low-certainty evidence); no cardiovascular mortality (2 trials; 446 participants; low-certainty evidence); SAE 34/424 (8%) versus 27/450 (6%), RR 1.68 (95% CI 0.54 to 5.21); P = 0.37; 3 trials; 874 participants; low-certainty evidence; no NFS (1 trial; 233 participants; very low-certainty evidence); non-fatal MI 2/215 (0.9%) participants in the M+S group; 2 trials; 446 participants; low-certainty evidence; no microvascular complications (1 trial; 233 participants; low-certainty evidence).Four trials compared M+S (N = 2109) with metformin plus a sodium-glucose co-transporter 2 inhibitor (N = 3032): all-cause mortality was 13/2107 (0.6%) versus 19/3027 (0.6%), RR 0.96 (95% CI 0.44 to 2.09); 4 trials; 5134 participants; very low-certainty evidence; cardiovascular mortality 4/1327 (0.3%) versus 6/2262 (0.3%), RR 1.22 (95% CI 0.33 to 4.41); 3 trials; 3589 participants; very low-certainty evidence; SAE 315/2107 (15.5%) versus 375/3027 (12.4%), RR 1.02 (95% CI 0.76 to 1.37); 4 trials; 5134 participants; very low-certainty evidence; NFS 3/919 (0.3%) versus 7/1856 (0.4%), RR 0.87 (95% CI 0.22 to 3.34); 2 trials; 2775 participants; very low-certainty evidence; non-fatal MI 7/890 (0.8%) versus 8/1374 (0.6%), RR 1.43 (95% CI 0.49 to 4.18; 2 trials); 2264 participants; very low-certainty evidence; amputation of lower extremity 1/437 (0.2%) versus 1/888 (0.1%); very low-certainty evidence.Trials reported more hypoglycaemic episodes with M+S combination compared to all other metformin-antidiabetic agent combinations. Results for M+S versus metformin monotherapy were inconclusive. There were no RCTs comparing M+S with metformin plus insulin. We identified nine ongoing trials and two trials are awaiting assessment. Together these trials will include approximately 16,631 participants. AUTHORS' CONCLUSIONS There is inconclusive evidence whether M+S combination therapy compared with metformin plus another glucose-lowering intervention results in benefit or harm for most patient-important outcomes (mortality, SAEs, macrovascular and microvascular complications) with the exception of hypoglycaemia (more harm for M+S combination). No RCT reported on health-related quality of life.
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Affiliation(s)
- Kasper S Madsen
- University of CopenhagenFaculty of Health and Medical SciencesBlegdamsvej 3BCopenhagen NDenmark2200
| | - Pernille Kähler
- Faculty of Health and Medical SciencesCopenhagen Medical UniversityBlegdamsvej 3CopenhagenDenmark2100Ø
| | | | - Sten Madsbad
- Hvidovre Hospital, University of CopenhagenDepartment of EndocrinologyHvidovreDenmark
| | - Filip Gnesin
- Department 7652, RigshospitaletDepartment of Endocrinology, Diabetes and MetabolismBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Maria‐Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bernd Richter
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bianca Hemmingsen
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
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Singh AK, Unnikrishnan AG, Zargar AH, Kumar A, Das AK, Saboo B, Sinha B, Gangopadhyay KK, Talwalkar PG, Ghosal S, Kalra S, Joshi S, Sharma SK, Sriram U, Mohan V. Evidence-Based Consensus on Positioning of SGLT2i in Type 2 Diabetes Mellitus in Indians. Diabetes Ther 2019; 10:393-428. [PMID: 30706366 PMCID: PMC6437257 DOI: 10.1007/s13300-019-0562-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Indexed: 02/05/2023] Open
Abstract
The current diabetes management strategies not only aim at controlling glycaemic parameters but also necessitate continuous medical care along with multifactorial risk reduction through a comprehensive management concept. The sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a group of evolving antidiabetic agents that have the potential to play a pivotal role in the comprehensive management of patients with diabetes due to their diverse beneficial effects. SGLT2i provide moderate glycaemic control, considerable body weight and blood pressure reduction, and thus have the ability to lower the risk of macrovascular and microvascular complications. Some of the unique characteristics associated with SGLT2i, such as reduction in body weight (more visceral fat mass loss than subcutaneous fat loss), reduction in insulin resistance and improvement in β-cell function, as measured by homeostatic model assessment-β (HOMA-β) could be potentially beneficial and help in overcoming some of the challenges faced by Indian patients with diabetes. In addition, a patient-centric approach with individualised treatment during SGLT2i therapy is inevitable in order to reduce diabetic complications and improve quality of life. Despite their broad benefits profile, the risk of genital tract infections, volume depletion, amputations and diabetic ketoacidosis associated with SGLT2i should be carefully monitored. In this compendium, we systematically reviewed the literature from Medline, Cochrane Library, and other relevant databases and attempted to provide evidence-based recommendations for the positioning of SGLT2i in the management of diabetes in the Indian population.Funding: AstraZeneca Pharma India Limited.
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Affiliation(s)
| | | | - Abdul H Zargar
- Advanced Centre for Diabetes and Endocrine Care, Srinagar, Jammu and Kashmir, India
| | - Ajay Kumar
- Diabetes Care and Research Centre, Patna, Bihar, India
| | - Ashok K Das
- Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Banshi Saboo
- Diacare-Diabetes Care & Hormone Clinic, Ahmedabad, Gujarat, India
| | | | | | | | - Samit Ghosal
- Nightingale Hospital, Kolkata, West Bengal, India
| | - Sanjay Kalra
- Bharti Hospital & B.R.I.D.E, Karnal, Haryana, India
| | - Shashank Joshi
- Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | | | - Usha Sriram
- Clinical Endocrinology Education and Research (ACEER), Chennai, Tamil Nadu, India
| | - Viswanathan Mohan
- Dr Mohan's Diabetes Specialities Centre and Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
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23
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Parker ED, Wittbrodt ET, McPheeters JT, Frias JP. Comparison of healthcare resource utilization and costs in patients with type 2 diabetes initiating dapagliflozin versus sitagliptin. Diabetes Obes Metab 2019; 21:227-233. [PMID: 30101553 DOI: 10.1111/dom.13502] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/07/2018] [Accepted: 08/09/2018] [Indexed: 01/10/2023]
Abstract
AIMS To compare healthcare costs and utilization in patients with type 2 diabetes (T2D) who initiated dapagliflozin (DAPA) with costs and utilization in those who initiated sitagliptin (SITA) in a real-world setting. MATERIALS AND METHODS This was a retrospective study of health plan enrollees in two US commercial claims databases or Medicare Part D. The study population comprised adult patients with T2D who initiated DAPA or SITA between January 1, 2014 and April 30, 2015. DAPA and SITA initiators were propensity-score-matched, and healthcare utilization and costs during the 1-year follow-up period were compared. Analyses were conducted separately for patients with evidence of oral antidiabetic drug (OAD) monotherapy use at baseline. RESULTS A total of 2722 patients were included in each matched cohort. Follow-up unadjusted all-cause costs ($16 065 and $17 281; P = 0.135) and diabetes-related costs ($9697 and $9354; P = 0.539) were similar in the DAPA and SITA cohorts. Higher office and outpatient visit costs in the SITA group were offset by higher pharmacy costs in the DAPA group. In the subgroup of 1804 patients with OAD monotherapy use at baseline, patients in the SITA group had higher total all-cause costs compared with those in the DAPA group ($14 884 vs. $12 353; P = 0.026). CONCLUSION Patients who initiated DAPA or SITA had similar all-cause and diabetes-related healthcare costs over 1 year of follow-up. In the subgroup of patients treated with OAD monotherapy at baseline (84% metformin monotherapy), those who initiated DAPA as add-on therapy had lower costs than patients who added SITA.
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Affiliation(s)
- Emily D Parker
- Health Economics and Outcomes Research, Optum, Eden Prairie, Minnesota
| | - Eric T Wittbrodt
- Health Economics and Outcomes Research, AstraZeneca, Wilmington, Delaware
| | | | - Juan P Frias
- National Research Institute, Los Angeles, California
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24
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Willis M, Asseburg C, Neslusan C. Conducting and interpreting results of network meta-analyses in type 2 diabetes mellitus: A review of network meta-analyses that include sodium glucose co-transporter 2 inhibitors. Diabetes Res Clin Pract 2019; 148:222-233. [PMID: 30641163 DOI: 10.1016/j.diabres.2019.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 12/04/2018] [Accepted: 01/04/2019] [Indexed: 11/27/2022]
Abstract
AIMS Network meta-analyses (NMAs) are valuable ways to generate comparative effectiveness data for therapies available to treat type 2 diabetes mellitus (T2DM). This review assesses NMAs that evaluate sodium glucose co-transporter 2 (SGLT2) inhibitors for treatment of T2DM and discusses potential issues in conducting and interpreting NMAs. METHODS A systematic literature search was conducted on September 13, 2018 using the search terms "network meta-analysis," "SGLT2," variations of these terms, and individual SGLT2 inhibitor names. Extracted data included NMA objectives, methods, target populations, treatments, study endpoints, length of follow-up, and funding. Differences between NMAs were investigated. RESULTS Thirty-five full-length publications met criteria for inclusion. In most NMAs, the target population was defined by therapeutic regimen (e.g., combination with metformin). Follow-up intervals permitted in NMAs varied considerably (range, 4-208 weeks). Twenty-nine NMAs included dapagliflozin, 28 evaluated canagliflozin, and 27 evaluated empagliflozin. Nine NMAs used frequentist methods; 16 used Bayesian methods. Six NMAs were funded by pharmaceutical manufacturers. Heterogeneity across NMAs was seen in scope, time frame, and other aspects of analytic design. CONCLUSIONS Although this review indicates that methodological guidelines for reporting NMAs were generally followed, it also emphasizes the need for T2DM-specific guidance requiring clear reporting of NMA scope and objectives to aid appropriate interpretation and use of NMA results.
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Affiliation(s)
- Michael Willis
- The Swedish Institute for Health Economics, Box 2127, Lund 220 02, Sweden.
| | - Christian Asseburg
- The Swedish Institute for Health Economics, Box 2127, Lund 220 02, Sweden.
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25
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Jia Y, Lao Y, Zhu H, Li N, Leung SW. Is metformin still the most efficacious first-line oral hypoglycaemic drug in treating type 2 diabetes? A network meta-analysis of randomized controlled trials. Obes Rev 2019; 20:1-12. [PMID: 30230172 DOI: 10.1111/obr.12753] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/11/2018] [Accepted: 07/11/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The objective of the study is to compare the efficacy of hypoglycaemic drugs for type 2 diabetes mellitus (T2DM) by network meta-analysis of randomized controlled trials (RCTs). METHODS We compared 11 major oral hypoglycaemic drugs under five categories evaluated by RCTs as drug monotherapy for the patients with T2DM, measuring glycosylated haemoglobin (%) or fasting plasma glucose (mmol L-1 ) as outcomes. RCT quality was assessed with the Cochrane risk of bias tool. Network meta-analysis estimated the mean differences and 95% credible intervals. Subgroup and sensitivity analyses were performed to determine the results robustness. The Grading of Recommendation, Assessment, Development, and Evaluation evidence strength was assessed. RESULTS Seventy-five RCTs including 33,830 patients were identified. Their study quality was high. Regarding glycosylated haemoglobin, top three anti-diabetics were repaglinide (mean differences -1.39 [95% credible intervals -1.75 to -1.03]), gliclazide (-1.37 [-2.04 to -0.71]) and metformin (-1.13 [-1.37 to -0.90]), against placebo. Regarding fasting plasma glucose, top three anti-diabetics were repaglinide (-2.01 [-2.75 to -0.97]), metformin (-1.72 [-2.16 to -1.27]) and glipizide (-1.57 [-2.44 to -0.64]), against placebo. There was no difference between metformin and repaglinide. Subgroup and sensitivity analyses found the results to be robust. The evidence strength was moderate to high. CONCLUSION This meta-analysis showed that repaglinide and metformin would be the most efficacious oral drugs for first-line monotherapy of T2DM.
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Affiliation(s)
- Y Jia
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China
| | - Y Lao
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China
| | - H Zhu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China
| | - N Li
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China
| | - S-W Leung
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China.,School of Informatics, University of Edinburgh, Edinburgh, UK
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26
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Mosleh W, Sharma A, Sidhu MS, Page B, Sharma UC, Farkouh ME. The Role of SGLT-2 Inhibitors as Part of Optimal Medical Therapy in Improving Cardiovascular Outcomes in Patients with Diabetes and Coronary Artery Disease. Cardiovasc Drugs Ther 2018; 31:311-318. [PMID: 28536852 DOI: 10.1007/s10557-017-6729-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The optimal treatment approach to patients with coronary artery disease (CAD), including those with type 2 diabetes mellitus (T2DM), has been extensively evaluated. Several trials of stable ischemic heart disease including patients with T2DM have demonstrated that medical management is comparable to revascularization in terms of mortality and rates of major adverse cardiovascular events (MACE). There has been a growing appreciation for optimal medical therapy's (OMT) role in improving clinical outcomes. It is vital to target T2DM patients to prevent or delay MACE events through advanced OMT, ultimately delaying if not avoiding the need for revascularization. There has been significant evolution in the development of pharmacologic management of T2DM patients. Sodium-glucose co-transporter-2 (SGLT2) inhibitors are a new pharmacologic therapy with tremendous potential to alter clinical practice and influence practice guidelines. SGLT2-inhibitors have great potential in reducing MACE in patients with T2DM and CAD. Empagliflozin should be considered as a part of OMT among these patients. If results similar to the EMPA-REG OUTCOMES trial are replicated in other trials, the use of these pharmacologic agents as a part of OMT may narrow the gap between revascularization and OMT alone in patients with T2DM and multi-vessel disease. Future studies on the role of SLGT-2 inhibitors with regard to heart failure outcomes are needed to elucidate the mechanisms and clinical effects in this vulnerable population.
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Affiliation(s)
- Wassim Mosleh
- University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Abhinav Sharma
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Mandeep S Sidhu
- Department of Medicine, Albany Medical College, Albany Medical Center, Albany, NY, USA
| | - Brian Page
- University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Umesh C Sharma
- University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Michael E Farkouh
- Peter Munk Cardiac Centre, University Health Network, 585 University Avenue, 4N474, Toronto, ON, M5G 2N2, Canada. .,The Heart and Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, University of Toronto, Toronto, ON, Canada.
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27
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Cho YK, Kim Y, Kang YM, Lee SE, Park J, Lee WJ, Jung CH. Comparison between sodium-glucose cotransporter 2 inhibitors and pioglitazone as additions to insulin therapy in type 2 diabetes patients: A systematic review with an indirect comparison meta-analysis. J Diabetes Investig 2018; 9:882-892. [PMID: 29215196 PMCID: PMC6031497 DOI: 10.1111/jdi.12787] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/10/2017] [Accepted: 11/30/2017] [Indexed: 02/06/2023] Open
Abstract
AIMS/INTRODUCTION We aimed to evaluate the efficacy and safety of pioglitazone (PIO) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) as additions to insulin therapy for the management of type 2 diabetes mellitus. MATERIALS AND METHODS We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov through December 2016. Randomized controlled trials published in English that compared SGLT2i plus insulin (SGLT2i/INS) or PIO plus insulin (PIO/INS) with placebo plus insulin (PCB/INS) in type 2 diabetes mellitus patients were included. We compared the efficacy and safety between SGLT2i/INS and PIO/INS indirectly. RESULTS A total of 14 randomized controlled trials comparing 7,226 participants were included (8 SGLT2i and 6 PIO studies). SGLT2i/INS achieved similar reductions in hemoglobin A1c (weighted mean difference [WMD] -0.01% [-0.1 mmol/mol], 95% confidence interval [CI] -0.25 to 0.22% [-2.7 to -2.4 mmol/mol]; P = 0.896) and fasting plasma glucose (WMD -0.90 mg/dL, 95% CI: -15.50 to 13.71 mg/dL; P = 0.904), and a similar proportion of participants achieved hemoglobin A1c <7.0% (<53.0 mmol/mol; relative risk 0.98, 95% CI: 0.73 to 1.33; P = 0.917) as compared with the PIO/INS group, with greater weight reduction (WMD -4.54 kg, 95% CI: -5.67 to -3.41 kg; P < 0.001). PIO/INS showed non-significant trends toward a higher risk of hypoglycemia (relative risk 1.15, 95% CI: 0.97 to 1.35; P = 0.102) and higher reduction of total daily insulin doses (WMD -2.45 IU/day, 95% CI: -7.30 to 2.40 IU/day; P = 0.438). CONCLUSIONS Both PIO and SGLT2i are feasible adjunctive oral agents to pre-existing insulin therapy in individuals with inadequately controlled type 2 diabetes mellitus.
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Affiliation(s)
- Yun Kyung Cho
- Department of Internal MedicineAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Ye‐Jee Kim
- Clinical Epidemiology and BiostatisticsAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Yu Mi Kang
- Department of Internal MedicineAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Seung Eun Lee
- Department of Internal MedicineAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Joong‐Yeol Park
- Department of Internal MedicineAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Woo Je Lee
- Department of Internal MedicineAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Chang Hee Jung
- Department of Internal MedicineAsan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
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28
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Avogaro A, Delgado E, Lingvay I. When metformin is not enough: Pros and cons of SGLT2 and DPP-4 inhibitors as a second line therapy. Diabetes Metab Res Rev 2018; 34:e2981. [PMID: 29320602 DOI: 10.1002/dmrr.2981] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 11/28/2017] [Accepted: 12/21/2017] [Indexed: 12/23/2022]
Abstract
The newer oral therapies for type 2 diabetes mellitus, dipeptidyl peptidase-4 (DPP-4) inhibitors and sodium glucose cotransporter 2 (SGLT2) inhibitors, have advantages over older agents. Dipeptidyl peptidase-4 inhibitors are weight neutral and have few adverse effects. Sodium glucose cotransporter 2 inhibitors have additional benefits: weight loss, blood pressure reduction, cardiovascular risk reduction, and renoprotective effects. Sodium glucose cotransporter 2 inhibitors have increased risk of urogenital infections and possible risk of "euglycaemic" diabetic ketoacidosis. It is important to balance the benefits over the older-oral therapies as these agents are more expensive; yet some analyses suggest that they are within the limits of what is considered cost-effective in health care. We discuss the relative merits and drawbacks of these 2 classes and consider their roles in the treatment of type 2 diabetes mellitus. We suggest a number of patient profiles where early use of these agents could be used. We favour the use of SGLT2 inhibitors over DPP-4 inhibitors as add on therapy to metformin when glycaemic targets have not been achieved given their similar glycaemic efficacy and the additional benefits of SGLT2 inhibitors. We particularly favour SGLT2 inhibitors in those where additional weight loss and blood pressure reductions are desired, and in patients with heart failure or cardiovascular disease. Care should be taken to warn patients about genital fungal infections and to avoid use in people with risk factors for SGLT2 associated ketoacidosis. We favour DPP-4 inhibitors in those where side effects of other agents are of concern, the frail elderly population, and those with renal disease precluding SGTL2 inhibitor use.
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Affiliation(s)
- Angelo Avogaro
- Department of Internal Medicine, Unit of Metabolic Disease, University of Padova, Padova, Italy
| | - Elías Delgado
- Department of Endocrinology and Nutrition, University of Oviedo, Oviedo, Spain
- Endocrinology and Nutrition Department, Hospital Universitario Central de Asturias, Oviedo, Spain
- Metabolism Unit, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Asturias, Spain
| | - Ildiko Lingvay
- Internal Medicine/Endocrinology and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Johnston R, Uthman O, Cummins E, Clar C, Royle P, Colquitt J, Tan BK, Clegg A, Shantikumar S, Court R, O'Hare JP, McGrane D, Holt T, Waugh N. Canagliflozin, dapagliflozin and empagliflozin monotherapy for treating type 2 diabetes: systematic review and economic evaluation. Health Technol Assess 2018; 21:1-218. [PMID: 28105986 DOI: 10.3310/hta21020] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Most people with type 2 diabetes are overweight, so initial treatment is aimed at reducing weight and increasing physical activity. Even modest weight loss can improve control of blood glucose. If drug treatment is necessary, the drug of first choice is metformin. However, some people cannot tolerate metformin, which causes diarrhoea in about 10%, and it cannot be used in people with renal impairment. This review appraises three of the newest class of drugs for monotherapy when metformin cannot be used, the sodium-glucose co-transporter 2 (SGLT2) inhibitors. OBJECTIVE To review the clinical effectiveness and cost-effectiveness of dapagliflozin (Farxiga, Bristol-Myers Squibb, Luton, UK), canagliflozin (Invokana, Janssen, High Wycombe, UK) and empagliflozin (Jardiance, Merck & Co., Darmstadt, Germany), in monotherapy in people who cannot take metformin. SOURCES MEDLINE (1946 to February 2015) and EMBASE (1974 to February 2015) for randomised controlled trials lasting 24 weeks or more. For adverse events, a wider range of studies was used. Three manufacturers provided submissions. METHODS Systematic review and economic evaluation. A network meta-analysis was carried out involving the three SGLT2 inhibitors and key comparators. Critical appraisal of submissions from three manufacturers. RESULTS We included three trials of dapagliflozin and two each for canagliflozin and empagliflozin. The trials were of good quality. The canagliflozin and dapagliflozin trials compared them with placebo, but the two empagliflozin trials included active comparators. All three drugs were shown to be effective in improving glycaemic control, promoting weight loss and lowering blood pressure (BP). LIMITATIONS There were no head-to-head trials of the different flozins, and no long-term data on cardiovascular outcomes in this group of patients. Most trials were against placebo. The trials were done in patient groups that were not always comparable, for example in baseline glycated haemoglobin or body mass index. Data on elderly patients were lacking. CONCLUSIONS Dapagliflozin, canagliflozin and empagliflozin are effective in improving glycaemic control, with added benefits of some reductions in BP and weight. Adverse effects are urinary and genital tract infections in a small proportion of users. In monotherapy, the three drugs do not appear cost-effective compared with gliclazide or pioglitazone, but may be competitive against sitagliptin (Januvia, Boehringer Ingelheim, Bracknell, UK). FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Olalekan Uthman
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | | | | | - Pamela Royle
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | | | - Bee Kang Tan
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | | | - Saran Shantikumar
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | - J Paul O'Hare
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
| | | | - Tim Holt
- University of Oxford, Oxford, UK
| | - Norman Waugh
- Warwick Evidence, Division of Health Sciences, University of Warwick, Coventry, UK
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Sugiyama S, Jinnouchi H, Kurinami N, Hieshima K, Yoshida A, Jinnouchi K, Nishimura H, Suzuki T, Miyamoto F, Kajiwara K, Jinnouchi T. Dapagliflozin Reduces Fat Mass without Affecting Muscle Mass in Type 2 Diabetes. J Atheroscler Thromb 2017; 25:467-476. [PMID: 29225209 PMCID: PMC6005223 DOI: 10.5551/jat.40873] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
AIM Sodium-glucose co-transporter 2 inhibitor (SGLT2i) therapy has been demonstrated to improve glycemic control and reduce body weight and fat mass in type 2 diabetes mellitus (T2DM). Here, our aim was to investigate the effects of SGLT2i dapagliflozin-treatment on body muscle mass and muscle fat content in patients with T2DM. METHODS We prospectively recruited uncontrolled (hemoglobin A1c [HbA1c] >7%) Japanese T2DM patients who had a body mass index (BMI) <35 kg/m2. Patients were treated with dapagliflozin (5 mg/day) or non-SGLT2i medicines for six months to improve HbA1c. We investigated changes in body composition using bioelectrical impedance analysis and changes in psoas muscle mass using abdominal computed tomography (CT). RESULTS Subjects were 50 T2DM patients (72% male) with a mean age of 56.1 years, mean BMI of 27.1 kg/m2 and mean HbA1c of 7.9%. HbA1c, body weight, and BMI were significantly decreased in both treatment groups, and the HbA1c decrease was not significantly different between groups. Dapagliflozin treatment significantly decreased body weight and total fat mass without affecting skeletal muscle mass. The absolute change in soft lean mass and skeletal muscle mass was not significantly different between groups. Dapagliflozin treatment did not significantly decrease psoas muscle index, and the absolute change in this index was not significantly different between groups. Dapagliflozin therapy also produced a significant increase in CT radiation attenuation in the third lumbar paraspinal muscles compared with non-SGLT2i therapy. CONCLUSIONS Treatment with dapagliflozin for six months significantly improved glycemic control and reduced body weight without reducing muscle mass in T2DM patients.
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Affiliation(s)
- Seigo Sugiyama
- Diabetes Care Center, Jinnouchi Hospital.,Cardiovascular Division, Diabetes Care Center, Jinnouchi Hospital
| | - Hideaki Jinnouchi
- Diabetes Care Center, Jinnouchi Hospital.,Cardiovascular Division, Diabetes Care Center, Jinnouchi Hospital.,Division of Preventive Cardiology, Department of Cardiovascular Medicine, Kumamoto University Hospital
| | | | | | | | | | | | | | | | - Keizo Kajiwara
- Diabetes Care Center, Jinnouchi Hospital.,Cardiovascular Division, Diabetes Care Center, Jinnouchi Hospital
| | - Tomio Jinnouchi
- Diabetes Care Center, Jinnouchi Hospital.,Cardiovascular Division, Diabetes Care Center, Jinnouchi Hospital
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Fadini GP, Zatti G, Consoli A, Bonora E, Sesti G, Avogaro A. Rationale and design of the DARWIN-T2D (DApagliflozin Real World evIdeNce in Type 2 Diabetes): A multicenter retrospective nationwide Italian study and crowdsourcing opportunity. Nutr Metab Cardiovasc Dis 2017; 27:1089-1097. [PMID: 28967594 DOI: 10.1016/j.numecd.2017.08.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/26/2017] [Accepted: 08/01/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Randomized controlled trials (RCTs) in the field of diabetes have limitations inherent to the fact that design, setting, and patient characteristics may be poorly transferrable to clinical practice. Thus, evidence from studies using routinely accumulated clinical data are increasingly valued. AIMS We herein describe rationale and design of the DARWIN-T2D (DApagliflozin Real World evIdeNce in Type 2 Diabetes), a multicenter retrospective nationwide study conducted at 50 specialist outpatient clinics in Italy and promoted by the Italian Diabetes Society. DATA SYNTHESIS The primary objective of the study is to describe the baseline clinical characteristics (particularly HbA1c) of patients initiated on dapagliflozin from marketing authorization approval to the end of 2016. Secondary and exploratory objectives will evaluate the changes in glycaemic and extraglycaemic efficacy parameters after initiation of dapagliflozin or after initiation of comparator glucose lowering medications (DPP-4 inhibitors, gliclazide extended release, and long-acting GLP-1 receptor agonists). An automated software will extract relevant data from the same electronic chart system at all centres, thereby minimizing data treatment and human intervention. CONCLUSION The study is expected to collect an enormous dataset of information on dapagliflozin- and comparator-using patients. After study completion, the Italian Diabetes Society will launch an open crowdsourcing call on the DARWIN-T2D database, challenging diabetes researchers to apply their ideas and approaches to address new unmet needs and knowledge gaps in diabetes. We believe this will move DARWIN-T2D to the next generation of real world studies.
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Affiliation(s)
- G P Fadini
- Department of Medicine, University of Padova, 35128 Padova, Italy.
| | - G Zatti
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - A Consoli
- Department of Medicine and Aging Science, "G. D'Annunzio" University of Chieti, 68100 Chieti, Italy
| | - E Bonora
- Department of Medicine, University of Verona, 37154 Verona, Italy
| | - G Sesti
- Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, 88100 Catanzaro, Italy
| | - A Avogaro
- Department of Medicine, University of Padova, 35128 Padova, Italy
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Abstract
BACKGROUND Due to the chronic nature of type 2 diabetes (T2D), it is essential for an anti-diabetic drug to have durable efficacy and a good long-term safety profile. Dapagliflozin is a member of a unique class of anti-diabetic drugs that inhibit the sodium-glucose cotransporter 2 (SGLT-2) in the renal tubules and have an insulin-independent mechanism of action. In short-term studies (≤ 24 weeks), dapagliflozin reduced glycated hemoglobin (A1c), weight, and systolic blood pressure, and had a good safety profile. METHODS This review summarizes the findings of long-term studies that evaluated the efficacy and safety of dapagliflozin. RESULTS These findings indicate that dapagliflozin is effective as monotherapy and in combination with other anti-hyperglycemic agents, including insulin and oral anti-diabetic therapies, in improving glycemic control and reducing blood pressure and weight for up to 4 years. The findings were fairly consistent across various patient populations with T2D, including those with cardiovascular disease (CVD) and mild renal impairment. Extended use of dapagliflozin was not associated with an increase in safety signals over time. Frequently observed adverse events (AEs) were consistent with the drug's mechanism of action and were generally mild in intensity. No substantial impact of dapagliflozin on renal function was observed, and findings show that the drug is safe in T2D patients with CVD or mild renal impairment, as well as elderly patients. CONCLUSIONS The findings across the studies support the use of dapagliflozin for the long-term treatment of T2D across a broad spectrum of patients.
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Affiliation(s)
- Serge Jabbour
- a Sidney Kimmel Medical College at Thomas Jefferson University , Philadelphia , PA , USA
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Imprialos KP, Stavropoulos K, Doumas M, Karagiannis A, Athyros VG. The effect of SGLT2 inhibitors on cardiovascular events and renal function. Expert Rev Clin Pharmacol 2017; 10:1251-1261. [DOI: 10.1080/17512433.2017.1370371] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Konstantinos P. Imprialos
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Stavropoulos
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Michael Doumas
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Department of Medicine, VAMC George Washington University, Washington, DC, USA
| | - Asterios Karagiannis
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasilios G. Athyros
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Fioretto P, Avogaro A. Dapagliflozin: potential beneficial effects in the prevention and treatment of renal and cardiovascular complications in patients with type 2 diabetes. Expert Opin Pharmacother 2017; 18:517-527. [PMID: 28277831 DOI: 10.1080/14656566.2017.1300253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Diabetic kidney disease is the leading cause of end-stage renal disease, a significant contributor to cardiovascular (CV) disease, responsible for much of the morbidity and mortality in patients with type 2 diabetes (T2DM). Strategies to slow or prevent the onset and progression of diabetic kidney disease are critical for effectively managing T2DM and reducing CV risk. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are effective antidiabetic agents, which may provide nephroprotective and CV protective effects. Areas covered: This review examines the role of the kidney in glucose homeostasis, discusses renal hemodynamic changes in diabetes, and outlines the major hypotheses regarding the mechanisms underlying renal injury in diabetes. The potential benefits of SGLT2 inhibitors in the prevention and treatment of CV complications in patients with T2DM are reviewed, with particular focus on dapagliflozin. Expert opinion: Dapagliflozin and other SGLT2 inhibitors have the capacity to decrease hyperglycemia and visceral fat, components of the metabolic syndrome particularly associated with the progression of CV disease. However, the mechanisms of action of SGLT2 inhibitors resulting in their positive CV effects remain unclear. Furthermore, the mechanism of action of SGLT2 inhibitors on heart function in non-diabetic patients with decompensated heart failure remains to be explored.
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Affiliation(s)
- Paola Fioretto
- a Department of Medicine , University of Padua , Padua , Italy
| | - Angelo Avogaro
- b Unit of Metabolic Diseases, Department of Medicine , University of Padua , Padua , Italy
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Hankins M, Tsai K, Kim J, Hammar N. Early drug use of dapagliflozin prescribed by general practitioners and diabetologists in Germany. Diabetes Res Clin Pract 2017; 125:29-38. [PMID: 28131071 DOI: 10.1016/j.diabres.2016.10.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 10/12/2016] [Accepted: 10/30/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Dapagliflozin is an inhibitor of the human sodium-glucose co-transporter 2 (SGLT2) that has been shown to improve glycaemic control in patients with type 2 diabetes mellitus (T2DM). This study aimed to evaluate the characteristics and treatment patterns of dapagliflozin users in comparison to users of other anti-diabetic (AD) treatments in Germany. METHODS Data from patients with T2DM initiating at least one prescription for dapagliflozin or other AD therapy between November 2012 and April 2014 were collected from the IMS German Disease Analyzer database. RESULTS The use of dapagliflozin combination therapy (n=1034; 74%) was more common than monotherapy (n=371; 26%). In comparison with other AD therapy users, a higher percentage of dapagliflozin users were ⩽64years of age (62.3% vs. 36.4%), and a higher proportion were male (59.1% vs. 53.6%). The average duration of diabetes was comparable between dapagliflozin patients and other AD therapy users (5.7yearsvs. 5.5years), however higher levels of HbA1c were found in dapagliflozin users (8.2% (66mmol/mol) vs. 7.5% (58mmol/mol). For the vast majority (71.5% of 10mg dapagliflozin users and 88.9% of 5mg users), dapagliflozin was prescribed in combination with other AD therapy. CONCLUSIONS Patients starting on dapagliflozin differed in several demographic and health-related respects to patients starting another AD therapy during the same period. Dapagliflozin was predominantly used as a component of combination therapy, adding on to existing therapy. After initiation, switching to other AD treatments or adding to therapy was comparatively rare during the first year.
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Affiliation(s)
- Matthew Hankins
- Real World Evidence Solutions, QuintilesIMS, London, UK; Institute of Pharmaceutical Science, King's College, London.
| | - Katherine Tsai
- Medical Evidence & Observational Research, Global Medical Affairs, AstraZeneca, Gaithersburg, USA
| | - Joseph Kim
- Real World Evidence Solutions, QuintilesIMS, London, UK; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London
| | - Niklas Hammar
- Medical Evidence & Observational Research, Global Medical Affairs, AstraZeneca, Mölndal, Sweden; Department of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
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Han JH, Oh TJ, Lee G, Maeng HJ, Lee DH, Kim KM, Choi SH, Jang HC, Lee HS, Park KS, Kim YB, Lim S. The beneficial effects of empagliflozin, an SGLT2 inhibitor, on atherosclerosis in ApoE -/- mice fed a western diet. Diabetologia 2017; 60:364-376. [PMID: 27866224 DOI: 10.1007/s00125-016-4158-2] [Citation(s) in RCA: 186] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 10/21/2016] [Indexed: 02/06/2023]
Abstract
AIMS/HYPOTHESIS A recent large clinical study has shown that empagliflozin has a lower rate of cardiovascular and all-cause mortality when compared with placebo in patients with type 2 diabetes. We investigated the effect of empagliflozin (compared with glimepiride) on the progression of atherosclerosis, and its possible mechanisms of action. METHODS Forty-eight 5-week-old male ApoE -/- mice were fed a western diet for 20 weeks and divided into four groups: control (saline, 154 mmol/l NaCl), glimepiride 0.1 mg/kg, empagliflozin 1 mg/kg and empagliflozin 3 mg/kg (n = 12/group). Plaque size and composition in the aortic arch/valve areas and cardiovascular risk variables in the blood and tissues were evaluated. Insulin resistance was estimated by HOMA and adiponectin levels. Body composition was determined using dual-energy x-ray absorptiometry. RESULTS After 8 weeks of treatment, the empagliflozin and glimepiride groups exhibited decreased blood glucose levels. Atherosclerotic plaque areas in the aortic arch/valve were significantly smaller in the empagliflozin groups than in the control or glimepiride groups. Insulin resistance and circulating concentrations of TNF-α, IL-6, monocyte chemoattractant protein-1 (MCP-1), serum amyloid A and urinary microalbumin decreased after empagliflozin treatment, and this significantly correlated with plaque size. Empagliflozin treatment reduced weight and fat mass, lipid droplets in the liver, fat cell size, mRNA expression of Tnf, Il6 and Mcp-1 (also known as Ccl2) and the infiltration of inflammatory cells in plaque and adipose tissue compared with the control or glimepiride group. Empagliflozin treatment increased adiponectin levels. CONCLUSIONS/INTERPRETATION Improvements in inflammation and insulin resistance seem to be mechanisms involved in the mitigation of atherosclerosis by empagliflozin.
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Affiliation(s)
- Ji Hye Han
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-city, South Korea, 463-070
| | - Tae Jung Oh
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-city, South Korea, 463-070
| | - Ghayoung Lee
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-city, South Korea, 463-070
| | - Hyo Jin Maeng
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-city, South Korea, 463-070
| | - Dong Hwa Lee
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-city, South Korea, 463-070
| | - Kyoung Min Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-city, South Korea, 463-070
| | - Sung Hee Choi
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-city, South Korea, 463-070
| | - Hak Chul Jang
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-city, South Korea, 463-070
| | - Hye Seung Lee
- Department of Pathology, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Kyong Soo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Young-Bum Kim
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-city, South Korea, 463-070.
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Lorenzi M, Ploug UJ, Langer J, Skovgaard R, Zoratti M, Jansen J. Liraglutide Versus SGLT-2 Inhibitors in People with Type 2 Diabetes: A Network Meta-Analysis. Diabetes Ther 2017; 8:85-99. [PMID: 27995594 PMCID: PMC5306116 DOI: 10.1007/s13300-016-0217-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION For people with type 2 diabetes (T2DM) inadequately controlled with oral antidiabetic drugs (OADs), evidence from both randomized controlled trials (RCTs) and real-world studies has demonstrated that treatment intensification with liraglutide offers effective glycemic control, weight reduction, and a lower risk of hypoglycemia compared to treatment intensification with insulin or additional OADs. Sodium glucose cotransporter 2 (SGLT-2) inhibitors are a new class of OADs that have also been shown to be effective in T2DM patients inadequately controlled with OADs. Currently there are no head-to-head RCTs comparing these to liraglutide. METHODS We aimed to evaluate the relative efficacy, using network meta-analysis (NMA), of treatment intensification with liraglutide and SGLT-2 inhibitors people with T2DM who have been treated with metformin (alone or in combination with SU, DPP-4, and TZD). We performed a systematic literature review to identify relevant RCTs comparing liraglutide (1.2 and 1.8 mg), canagliflozin (100 and 300 mg), empagliflozin (10 and 25 mg), or dapagliflozin (5 and 10 mg) to placebo. To strengthen the indirect evidence base, we also included non-placebo RCTs where sitagliptin (100 mg) was the active comparator. Bayesian NMA was performed on the following outcomes to assess the relative efficacy and safety of interventions: reduction (change) in HbA1c, weight, and fasting plasma glucose (FPG) as well as proportion reaching target HbA1c (<7%), and risk of hypoglycemia. Doses for each intervention were considered separately. RESULTS A total of 16 RCTs were identified. All trials were similar with respect to important baseline characteristics and study design. Both doses of liraglutide were generally statistically significantly superior to the SGLT-2s with respect to change from baseline in HbA1c and FPG as well as odds of reaching target HbA1c <7%. For weight, canagliflozin 300 mg was superior to liraglutide 1.2 mg, and SGLT-2s were generally associated with larger change from baseline in weight. For risk of major or minor hypoglycemia, no differences were found between treatments. CONCLUSIONS Compared to SGLT-2 inhibitors, liraglutide offers improvement in HbA1c and FPG. Reductions in weight are likely comparable between liraglutide and SGLT-2s. Liraglutide did not differ from SGLT-2s in terms of risk of hypoglycemia. Given the lack of head-to-head evidence, this analysis provides valuable insight into the comparative outcomes of liraglutide versus SGLT-2 inhibitors.
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Affiliation(s)
- Maria Lorenzi
- Precision Health Economics, 250-555 12 Street, Oakland, CA, 94607, USA.
| | | | - Jakob Langer
- Novo Nordisk, Vandtårnsvej 114, 2860, Søborg, Denmark
| | | | - Michael Zoratti
- Precision Health Economics, 250-555 12 Street, Oakland, CA, 94607, USA
| | - Jeroen Jansen
- Precision Health Economics, 250-555 12 Street, Oakland, CA, 94607, USA
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Analisi di Impatto Sul Budget di Empagliflozin Nel Trattamento Dei Pazienti Con Diabete di tipo 2 e Malattia Cardiovascolare Accertata. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2017. [DOI: 10.5301/grhta.5000263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Yu H, Woo VC. Emerging use of combination therapies for the management of type 2 diabetes - focus on saxagliptin and dapagliflozin. Diabetes Metab Syndr Obes 2017; 10:317-332. [PMID: 28769579 PMCID: PMC5533573 DOI: 10.2147/dmso.s117982] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
AIMS The aim of this article is to review the safety and efficacy data of dapagliflozin, saxagliptin, and their combination in the management of patients with type 2 diabetes. Evidence for the use of the single-tablet combination formulation is also presented. METHODS A nonsystematic literature review was performed using the Ovid, PubMed, and Google Scholar databases. RESULTS The addition of dapagliflozin/saxagliptin to metformin can lower mean hemoglobin A1c by as much as 1.47% and lead to weight loss of 0.5-2.0 kg. The risk of genital infections with combination therapy is lower than observed with dapagliflozin alone, suggestive of a protective effect. Adverse event risk at 52-week follow-up was not increased beyond that seen with either monotherapy. CONCLUSION Dapagliflozin/saxagliptin combination is generally well tolerated and is an effective tool in helping patients with diabetes improve glycemic control.
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Affiliation(s)
- Huan Yu
- Department of Medicine, Division of Endocrinology and Metabolism, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
- Correspondence: Huan Yu, Department of Medicine, Section of Endocrinology and Metabolism, Health Sciences Centre, University of Manitoba, 838-715 McDermot Avenue, Winnipeg, MB, Canada R3E 3P4, Tel +1 204 957 3218, Fax +1 204 943 3516, Email
| | - Vincent C Woo
- Department of Medicine, Division of Endocrinology and Metabolism, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
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Tzanetakos C, Tentolouris N, Kourlaba G, Maniadakis N. Cost-Effectiveness of Dapagliflozin as Add-On to Metformin for the Treatment of Type 2 Diabetes Mellitus in Greece. Clin Drug Investig 2016; 36:649-59. [PMID: 27221806 DOI: 10.1007/s40261-016-0410-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Type 2 diabetes mellitus (T2DM) is a chronic progressive disease that has been spread worldwide over the past three decades and associated with increased morbidity and mortality resulting in considerable socioeconomic implications for national healthcare systems. Effective management of disease is highly needed ensuring patients receive the best possible care within the available budget. The objective of this study was to evaluate the long-term cost-effectiveness of dapagliflozin, a sodium-glucose co-transporter-2 (SGLT-2) inhibitor, compared with a sulfonylurea (SU) or a dipeptidyl-peptidase-4 inhibitor (DPP-4i), when added to metformin, in T2DM patients inadequately controlled on metformin alone in Greece. METHODS The published and validated Cardiff diabetes model, a lifetime micro-simulation model, was adapted to a Greek healthcare setting to determine the incidence of micro- and macro-vascular complications and diabetes-specific and all-cause mortality. Clinical, cost, and utility data were retrieved from literature and assigned to model parameters to calculate total quality-adjusted life-years (QALYs) and total costs as well as incremental cost-effectiveness ratios (ICERs). The analysis was conducted from the perspective of a third-party payer in Greece. Uncertainty surrounding important model parameters was explored with univariate and probabilistic sensitivity analyses (PSA). RESULTS Over a patient's lifetime, dapagliflozin was associated with 0.48 and 0.04 incremental QALYs compared with SU and DPP-4i, respectively, at additional costs of €5142 and €756, respectively. The corresponding ICERs were €10,623 and €17,695 per QALY gained versus the treatment with SU and DPP-4i, respectively. Results were robust across various univariate and scenario analyses. At the defined willingness-to-pay threshold of €34,000 per QALY gained, PSA estimated that treatment with dapagliflozin had a 100 % and 79.7 % probability of being cost-effective relative to the SU and DPP-4i treatments. CONCLUSIONS Dapagliflozin in combination with metformin was shown to be a cost-effective treatment alternative for patients with T2DM whose metformin regimen does not provide sufficient glycemic control in a Greek healthcare setting.
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Affiliation(s)
- Charalampos Tzanetakos
- Department of Health Services Organization and Management, National School of Public Health, 196 Alexandras Avenue, 11521, Athens, Greece.
| | - Nicholas Tentolouris
- First Department of Propaedeutic and Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Georgia Kourlaba
- Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), "Aghia Sophia" Children`s Hospital, Athens, Greece
| | - Nikos Maniadakis
- Department of Health Services Organization and Management, National School of Public Health, 196 Alexandras Avenue, 11521, Athens, Greece
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41
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Solini A. Role of SGLT2 inhibitors in the treatment of type 2 diabetes mellitus. Acta Diabetol 2016; 53:863-870. [PMID: 27038028 DOI: 10.1007/s00592-016-0856-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 03/04/2016] [Indexed: 02/06/2023]
Abstract
In the last ten years, knowledge on pathophysiology of type 2 diabetes (T2DM) has significantly increased, with multiple failures (decreased incretin effect, increased lipolysis, increased glucagon secretion, neurotransmitters dysfunction) recognized as important contributors, together with decreased insulin secretion and reduced peripheral glucose uptake. As a consequence, the pharmacologic therapy of T2DM has been progressively enriched by several novel classes of drugs, trying to overcome these defects. The last, intriguing compounds come into the market are SGLT2 inhibitors, framing the kidney in a different scenario, not as site of a harmful disease complication, but rather as the means to correct hyperglycemia and fight the disease. This review aims to offer a short, updated overview of the role of these compounds in the treatment of T2DM, focusing on efficacy, ancillary albeit relevant clinical effects, safety, potential cardiovascular protection, positioning in common therapeutic algorithms.
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Affiliation(s)
- Anna Solini
- Department of Clinical and Experimental Medicine, University of Pisa, 56126, Pisa, Italy.
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42
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Storgaard H, Gluud LL, Bennett C, Grøndahl MF, Christensen MB, Knop FK, Vilsbøll T. Benefits and Harms of Sodium-Glucose Co-Transporter 2 Inhibitors in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0166125. [PMID: 27835680 PMCID: PMC5106000 DOI: 10.1371/journal.pone.0166125] [Citation(s) in RCA: 162] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/24/2016] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Sodium-glucose co-transporter 2 inhibitors (SGLT2-i) are a novel drug class for the treatment of diabetes. We aimed at describing the maximal benefits and risks associated with SGLT2-i for patients with type 2 diabetes. DESIGN Systematic review and meta-analysis. DATA SOURCES AND STUDY SELECTION We included double-blinded, randomised controlled trials (RCTs) evaluating SGLT2-i administered in the highest approved therapeutic doses (canagliflozin 300 mg/day, dapagliflozin 10 mg/day, and empagliflozin 25 mg/day) for ≥12 weeks. Comparison groups could receive placebo or oral antidiabetic drugs (OAD) including metformin, sulphonylureas (SU), or dipeptidyl peptidase 4 inhibitors (DPP-4-i). Trials were identified through electronic databases and extensive manual searches. Primary outcomes were glycated haemoglobin A1c (HbA1c) levels, serious adverse events, death, severe hypoglycaemia, ketoacidosis and CVD. Secondary outcomes were fasting plasma glucose, body weight, blood pressure, heart rate, lipids, liver function tests, creatinine and adverse events including infections. The quality of the evidence was assessed using GRADE. RESULTS Meta-analysis of 34 RCTs with 9,154 patients showed that SGLT2-i reduced HbA1c compared with placebo (mean difference -0.69%, 95% confidence interval -0.75 to -0.62%). We downgraded the evidence to 'low quality' due to variability and evidence of publication bias (P = 0.015). Canagliflozin was associated with the largest reduction in HbA1c (-0.85%, -0.99% to -0.71%). There were no differences between SGLT2-i and placebo for serious adverse events. SGLT2-i increased the risk of urinary and genital tract infections and increased serum creatinine, and exerted beneficial effects on bodyweight, blood pressure, lipids and alanine aminotransferase (moderate to low quality evidence). Analysis of 12 RCTs found a beneficial effect of SGLT2-i on HbA1c compared with OAD (-0.20%, -0.28 to -0.13%; moderate quality evidence). CONCLUSION This review includes a large number of patients with type 2 diabetes and found that SGLT2-i reduces HbA1c with a notable increased risk in non-serious adverse events. The analyses may overestimate the intervention benefit due bias.
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Affiliation(s)
- Heidi Storgaard
- Centre for Diabetes Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Lise L. Gluud
- Gastrounit, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark
| | - Cathy Bennett
- Centre for Technology Enabled Health Research, Coventry University, Coventry, United Kingdom
| | - Magnus F. Grøndahl
- Centre for Diabetes Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Mikkel B. Christensen
- Centre for Diabetes Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Pharmacology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Filip K. Knop
- Centre for Diabetes Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Novo Nordisk Foundation Centre for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tina Vilsbøll
- Centre for Diabetes Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Glennie JL, Kovacs Burns K, Oh P. Bringing patient centricity to diabetes medication access in Canada. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:599-611. [PMID: 27799802 PMCID: PMC5074731 DOI: 10.2147/ceor.s116570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Canada must become proactive in addressing type 2 diabetes. With the second highest rate of diabetes prevalence in the developed world, the number of Canadians living with diabetes will soon reach epidemic levels. Against international comparisons, Canada also performs poorly with respect to diabetes-related hospitalizations, mortality rates, and access to medications. Diabetes and its comorbidities pose a significant burden on people with diabetes (PWD) and their families, through out-of-pocket expenses for medications, devices, supplies, and the support needed to manage their illness. Rising direct and indirect costs of diabetes will become a drain on Canada's economy and undermine the financial stability of our health care system. Canada's approach to diabetes medication assessment and funding has created a patchwork of medication access across provinces. Access to treatments for those who rely on public programs is highly restricted compared to Canadians with private drug plans, as well in contrast with public payers in other countries. Each person living with diabetes has different needs, so a "patient-centric" approach ensures treatment focused on individual circumstances. Such tailoring is difficult to achieve, with the linear approach required by public payers. We may be undermining optimal care for PWD because of access policies that are not aligned with individualized approaches - and increasing overall health care costs in the process. The scope of Canada's diabetes challenge demands holistic and proactive solutions. Canada needs to get out from "behind the eight ball" and get "ahead of the curve" when it comes to diabetes care. Improving access to medications is one of the tools for getting there. Canada's "call to action" for diabetes starts with effective implementation of existing best practices. A personalized approach to medication access, to meet individual needs and optimize outcomes, is also a key enabler. PWD and prescribers need reimbursement approaches that allow them to use existing tools (ie, medications and supplies) to manage diabetes in a timely manner and to avoid and/or delay major downstream complications.
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Affiliation(s)
| | | | - Paul Oh
- Cardiac Rehabilitation and Secondary Prevention Program, UHN; Toronto Rehabilitation Institute and Peter Munk Cardiac Centre, Toronto, ON, Canada
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Batson S, Burton H. A Systematic Review of Methods for Handling Missing Variance Data in Meta-Analyses of Interventions in Type 2 Diabetes Mellitus. PLoS One 2016; 11:e0164827. [PMID: 27749930 PMCID: PMC5066955 DOI: 10.1371/journal.pone.0164827] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 09/30/2016] [Indexed: 12/14/2022] Open
Abstract
AIMS Meta-analysis is of critical importance to decision makers to assess the comparative efficacy and safety of interventions and is integral to health technology assessment. A major problem for the meta-analysis of continuous outcomes is that associated variance data are not consistently reported in trial publications. The omission of studies from a meta-analysis due to incomplete reporting may introduce bias. The objectives of this study are to summarise and describe the methods used for handling missing variance data in meta-analyses in populations with type 2 diabetes mellitus (T2DM). METHODS Electronic databases, Embase, MEDLINE, and the Cochrane Library (accessed June 2015), were systematically searched to identify meta-analyses of interventions in patients with T2DM. Eligible studies included those which analysed the change in HbA1c from baseline. RESULTS Sixty-seven publications reporting on meta-analyses of change in HbA1c from baseline in T2DM were identified. Approaches for dealing with missing variance data were reported in 41% of publications and included algebraic calculation, trial-level imputation, and no imputation. CONCLUSIONS Meta-analysis publications typically fail to report standardised approaches for dealing with missing variance data. While no particular imputation method is favoured, authors are discouraged from using a no-imputation approach. Instead, authors are encouraged to explore different approaches using sensitivity analyses and to improve the quality of reporting by documenting the methods used to deal with missing variance data.
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Katz PM, Leiter LA. The Role of the Kidney and SGLT2 Inhibitors in Type 2 Diabetes. Can J Diabetes 2016; 39 Suppl 5:S167-75. [PMID: 26654860 DOI: 10.1016/j.jcjd.2015.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 08/24/2015] [Accepted: 09/01/2015] [Indexed: 02/06/2023]
Abstract
Effective glycemic control reduces the risk for diabetes-related complications. However, the majority of patients with type 2 diabetes still do not achieve glycemic targets. Beyond metformin therapy, current practice guidelines for the management of type 2 diabetes recommend individualized treatment based on patient and agent characteristics. The sodium glucose cotransporter type 2 (SGLT2) inhibitors represent a novel treatment strategy, independent of impaired beta-cell function and insulin resistance. SGLT2 inhibitors decrease renal glucose reabsorption, thereby increasing urinary glucose excretion with subsequent reduction in plasma glucose levels and glycosylated hemoglobin concentrations. Current evidence suggests that they are effective as monotherapy or as add-ons to metformin either alone, or in combination with other oral glucose-lowering agents or insulin. They are generally well tolerated, though rates of lower urinary tract and genital mycotic infections are slightly increased. The advantages of this class include modest reductions in body weight and blood pressure, and low risk for hypoglycemia. Long-term safety data and results of ongoing cardiovascular outcome studies are awaited so we can fully understand the role that SGLT2 inhibitors will play in the comprehensive management of type 2 diabetes.
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Affiliation(s)
- Pamela M Katz
- Department of Medicine, Section of Endocrinology and Metabolism, University of Manitoba, St. Boniface Hospital, Winnipeg, Manitoba, Canada.
| | - Lawrence A Leiter
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Division of Endocrinology and Metabolism, University of Toronto, Toronto, Ontario, Canada
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Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitor Increases Circulating Zinc-Α2-Glycoprotein Levels in Patients with Type 2 Diabetes. Sci Rep 2016; 6:32887. [PMID: 27611858 PMCID: PMC5017191 DOI: 10.1038/srep32887] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 08/16/2016] [Indexed: 01/10/2023] Open
Abstract
ZAG has recently been characterized as a potent metabolic regulator, but the effect of anti-diabetic agents on ZAG in humans remains unknown. Our aim was to study the effects of SGLT2 inhibitor on circulating ZAG and ADI in nT2DM. 162 subjects with nT2DM were treated by a placebo or DAPA. After 3-months of DAPA therapy, HbA1c, FBG, 2h-PBG, FFA, TG, blood pressure, BMI, WHR, body weight, FAT%, FINS, and HOMA-IR in T2DM patients decreased significantly, whereas HDL-C was significantly increased. Importantly, circulating ZAG and ADI levels in these patients were also significantly increased after DAPA therapy. Basal ZAG levels were associated with changes in BMI, FAT%, TC, HbA1c, HDL-C and ADI at post-treatment, whereas basal ADI levels were associated with changes in FAT%, TC, HbA1c, FFA and HDL-c. In vitro, DAPA treatment showed increased ZAG expression and secretion in HepG2 cells. When combined with a PPAR-γinhibitor GW9662, the effect of DAPA on ZAG was abrogated. These findings suggest that circulating ZAG can be regulated by DAPA, and DAPA promotes the expression and secretion of ZAG in the liver via the activation of PPAR-γ. The changes in ZAG induced by DAPA may play a physiologic role in enhancing insulin sensitivity.
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47
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Pafili K, Maltezos E, Papanas N. Pharmacokinetic and pharmacodynamic drug evaluation of tofogliflozin for the treatment of type 2 diabetes. Expert Opin Drug Metab Toxicol 2016; 12:1367-1380. [DOI: 10.1080/17425255.2016.1229302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Kalliopi Pafili
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Efstratios Maltezos
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Nikolaos Papanas
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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Watson L, Das R, Farquhar R, Langerman H, Barnett AH. Consequences of delaying treatment intensification in type 2 diabetes: evidence from a UK database. Curr Med Res Opin 2016; 32:1465-75. [PMID: 26907851 DOI: 10.1185/03007995.2016.1157462] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Type 2 diabetes mellitus (TD2M) treatment focuses on achieving glycemic control, with HbA1c targeted at 6.5-7.5%. Clinicians commonly delay treatment intensification despite patients failing glycemic targets. This study evaluated longitudinal clinical and cost outcomes in patients failing metformin monotherapy using electronic medical records. RESEARCH DESIGN AND METHODS Adults with incident T2DM were identified in the UK Clinical Practice Research Datalink (CPRD) from 1 January 2000 to 31 March 2014. Patients were initiated on metformin monotherapy but had not reached target (HbA1c <7%). Patients were grouped by time to intensification of second-line therapy from first recorded HbA1c ≥7%: Group A, rapid intensification within 365 days; Group B, delayed intensification days 366-1824; Group C, never intensified. Patients were followed from day 366 for 5 years until end of study, switch to insulin, migration or death. MAIN OUTCOME MEASURES The study evaluated baseline clinical and medication characteristics which were re-evaluated each year, including HbA1c, weight, cholesterol and concomitant prescribing. RESULTS A total of 6710 patients were included (Group A 2647, Group B 2452, Group C 1611). Group A achieved a significant decline in HbA1c at 1 year post-index date compared to Groups B and C (-1.13% Group A; +0.26% Group B, +0.16% Group C). A significantly higher proportion of patients achieved HbA1c target < 7% in Group A (Group A [45.8%]; Group B [19.1%], p < 0.0001). Using an adjusted hazard model, Group A was found to achieve the HbA1c target from the index date significantly faster than Group B (hazard ratio 3.25 [95% CI 2.87-3.69]). The most commonly prescribed second-line medications were sulfonylureas in Groups A and B throughout observation and were associated with significant weight gain (+1.3 kg per patient) in the adjusted models. CONCLUSIONS Patients who were rapidly intensified achieved a maintained reduction in HbA1c faster than those with delayed intensification or no second-line therapy, despite a higher baseline HbA1c.
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Affiliation(s)
| | | | | | | | - Anthony H Barnett
- c Diabetes and Endocrine Centre , Heart of England NHS Foundation Trust and University of Birmingham , UK
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Zaccardi F, Webb DR, Htike ZZ, Youssef D, Khunti K, Davies MJ. Efficacy and safety of sodium-glucose co-transporter-2 inhibitors in type 2 diabetes mellitus: systematic review and network meta-analysis. Diabetes Obes Metab 2016; 18:783-94. [PMID: 27059700 DOI: 10.1111/dom.12670] [Citation(s) in RCA: 320] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 03/24/2016] [Accepted: 03/31/2016] [Indexed: 12/13/2022]
Abstract
AIM To assess the comparative efficacy and safety of sodium-glucose co-transporter-2 (SGLT2) inhibitors in adults with type 2 diabetes. METHODS We electronically searched randomized controlled trials (≥24 weeks) including canagliflozin, dapagliflozin or empagliflozin that were published up to 3 November 2015. Data were collected on cardiometabolic and safety outcomes and synthesized using network meta-analyses. RESULTS A total of 38 trials (23 997 participants) were included. Compared with placebo, all SGLT2 inhibitors reduced glycated haemoglobin (HbA1c), fasting plasma glucose (FPG), body weight and blood pressure, and slightly increased HDL cholesterol. Canagliflozin 300 mg reduced HbA1c, FPG and systolic blood pressure and increased LDL cholesterol to a greater extent compared with other inhibitors at any dose. At their highest doses, canagliflozin 300 mg reduced: HbA1c by 0.2% [95% confidence interval (CI) 0.1-0.3] versus both dapagliflozin 10 mg and empagliflozin 25 mg; FPG by 0.6 mmol/l (95% CI 0.3-0.9) and 0.5 mmol/l (95% CI 0.1-0.8) versus dapagliflozin and empagliflozin, respectively; and systolic blood pressure by 2 mmHg (95% CI 1.0-3.0) versus dapagliflozin; and increased LDL cholesterol by 0.13 mmol/l (95% CI 0.03-0.23) and 0.15 mmol/l (95% CI 0.06-0.23) versus dapagliflozin and empagliflozin, respectively. The highest doses of inhibitors had similar effects on body weight reduction. Canagliflozin 300 and 100 mg increased the risk of hypoglycaemia versus placebo, dapagliflozin 10 mg and empagliflozin 10 mg [odds ratios (ORs) 1.4-1.6]. Dapagliflozin 10 mg increased the risk of urinary tract infection versus placebo and empagliflozin 25 mg (ORs 1.4). All inhibitors similarly increased the risk of genital infection (ORs 4-6 versus placebo). CONCLUSIONS Although they increase the risk of genital infection, SGLT2 inhibitors are effective in improving cardiometabolic markers in type 2 diabetes, with canagliflozin 300 mg performing better in this respect than other inhibitors. Further studies will clarify whether these differences are likely to translate into differing long-term outcomes.
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Affiliation(s)
- F Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Center, Leicester Diabetes Centre, UHL NHS Trust, Leicester, UK
| | - D R Webb
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Center, Leicester Diabetes Centre, UHL NHS Trust, Leicester, UK
| | - Z Z Htike
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Center, Leicester Diabetes Centre, UHL NHS Trust, Leicester, UK
| | - D Youssef
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Center, Leicester Diabetes Centre, UHL NHS Trust, Leicester, UK
| | - K Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Center, Leicester Diabetes Centre, UHL NHS Trust, Leicester, UK
| | - M J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Center, Leicester Diabetes Centre, UHL NHS Trust, Leicester, UK
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50
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Tian M, Liang Z, Liu R, Li K, Tan X, Luo Y, Yang M, Gu HF, Liu H, Li L, Yang G. Effects of sitagliptin on circulating zinc-α2-glycoprotein levels in newly diagnosed type 2 diabetes patients: a randomized trial. Eur J Endocrinol 2016; 174:147-55. [PMID: 26546612 DOI: 10.1530/eje-15-0637] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 11/06/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Zinc-α2-glycoprotein (ZAG) has recently been characterized as a potent metabolic regulator. However, the effects of anti-diabetic agents on circulating ZAG levels in humans remain largely unknown. To explore the possible mechanisms by which the dipeptidyl peptidase-IV (DPP-IV) inhibitor improves insulin resistance, we investigated the effect of sitagliptin, a DPP-IV inhibitor, on circulating cytokine levels in newly diagnosed type 2 diabetes (nT2DM) patients. DESIGN AND METHODS A subset of 141 subjects with nT2DM were assigned to receive placebo (n=47) or sitagliptin (n=94) for 3 months. Before and after treatment, subjects received a 75 g oral glucose tolerance test, euglycemic-hyperinsulinemic clamp (EHC), and measurement of ZAG and adiponectin (ADI) concentrations. RESULTS Circulating ZAG levels were lower in nT2DM than in control individuals (P<0.01). After 3 months of sitagliptin treatment, HbA1c, fasting plasma glucose, postprandial glucose, 2-h insulin after glucose overload, triglycerides, and homeostasis model assessment of insulin resistance (HOMA-IR) were decreased significantly compared with pre-treatment (P<0.05 or P<0.01), whereas the glucose infusion rate during the stable period of the clamp (M values) during EHC were significantly increased (P<0.01). In addition, circulating ZAG and ADI concentrations were significantly increased along with improved glucose metabolism and insulin sensitivity compared with pre-treatment (both P<0.01) and the change of ZAG (ΔZAG) was positively associated with ΔADI, ΔHOMA-IR, ΔBMI, Δfasting insulin and negatively associated with Δ tumor necrosis factor-α (TNF-α). Furthermore, sitagliptin treatment resulted in significantly lowered plasma TNF-α level (P<0.05). CONCLUSION A low level of circulating ZAG is associated with insulin resistance and sitagliptin treatment significantly increases circulating ZAG levels. These observations have implications in relation to the mode of action of the DPP-IV inhibitor as an insulin sensitizing agent.
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Affiliation(s)
- Mingyuan Tian
- Department of EndocrinologyThe Second Affiliated Hospital, Chongqing Medical University, Chongqing, ChinaDpartment of Endocrinology9th People's Hospital of Chongqing, Chongqong, ChinaDepartment of EndocrinologyChongqing Three Gorges Central Hospital, Chongqing, ChinaDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Karolinska University Hospital, Solna, Stockholm, SwedenDepartment of PediatricsUniversity of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Zerong Liang
- Department of EndocrinologyThe Second Affiliated Hospital, Chongqing Medical University, Chongqing, ChinaDpartment of Endocrinology9th People's Hospital of Chongqing, Chongqong, ChinaDepartment of EndocrinologyChongqing Three Gorges Central Hospital, Chongqing, ChinaDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Karolinska University Hospital, Solna, Stockholm, SwedenDepartment of PediatricsUniversity of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Rui Liu
- Department of EndocrinologyThe Second Affiliated Hospital, Chongqing Medical University, Chongqing, ChinaDpartment of Endocrinology9th People's Hospital of Chongqing, Chongqong, ChinaDepartment of EndocrinologyChongqing Three Gorges Central Hospital, Chongqing, ChinaDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Karolinska University Hospital, Solna, Stockholm, SwedenDepartment of PediatricsUniversity of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Ke Li
- Department of EndocrinologyThe Second Affiliated Hospital, Chongqing Medical University, Chongqing, ChinaDpartment of Endocrinology9th People's Hospital of Chongqing, Chongqong, ChinaDepartment of EndocrinologyChongqing Three Gorges Central Hospital, Chongqing, ChinaDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Karolinska University Hospital, Solna, Stockholm, SwedenDepartment of PediatricsUniversity of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Xinrong Tan
- Department of EndocrinologyThe Second Affiliated Hospital, Chongqing Medical University, Chongqing, ChinaDpartment of Endocrinology9th People's Hospital of Chongqing, Chongqong, ChinaDepartment of EndocrinologyChongqing Three Gorges Central Hospital, Chongqing, ChinaDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Karolinska University Hospital, Solna, Stockholm, SwedenDepartment of PediatricsUniversity of Mississippi Medical Center, Jackson, Mississippi, USA Department of EndocrinologyThe Second Affiliated Hospital, Chongqing Medical University, Chongqing, ChinaDpartment of Endocrinology9th People's Hospital of Chongqing, Chongqong, ChinaDepartment of EndocrinologyChongqing Three Gorges Central Hospital, Chongqing, ChinaDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Karolinska University Hospital, Solna, Stockholm, SwedenDepartment of PediatricsUniversity of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Yong Luo
- Department of EndocrinologyThe Second Affiliated Hospital, Chongqing Medical University, Chongqing, ChinaDpartment of Endocrinology9th People's Hospital of Chongqing, Chongqong, ChinaDepartment of EndocrinologyChongqing Three Gorges Central Hospital, Chongqing, ChinaDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Karolinska University Hospital, Solna, Stockholm, SwedenDepartment of PediatricsUniversity of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Mengliu Yang
- Department of EndocrinologyThe Second Affiliated Hospital, Chongqing Medical University, Chongqing, ChinaDpartment of Endocrinology9th People's Hospital of Chongqing, Chongqong, ChinaDepartment of EndocrinologyChongqing Three Gorges Central Hospital, Chongqing, ChinaDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Karolinska University Hospital, Solna, Stockholm, SwedenDepartment of PediatricsUniversity of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Harvest F Gu
- Department of EndocrinologyThe Second Affiliated Hospital, Chongqing Medical University, Chongqing, ChinaDpartment of Endocrinology9th People's Hospital of Chongqing, Chongqong, ChinaDepartment of EndocrinologyChongqing Three Gorges Central Hospital, Chongqing, ChinaDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Karolinska University Hospital, Solna, Stockholm, SwedenDepartment of PediatricsUniversity of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Hua Liu
- Department of EndocrinologyThe Second Affiliated Hospital, Chongqing Medical University, Chongqing, ChinaDpartment of Endocrinology9th People's Hospital of Chongqing, Chongqong, ChinaDepartment of EndocrinologyChongqing Three Gorges Central Hospital, Chongqing, ChinaDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Karolinska University Hospital, Solna, Stockholm, SwedenDepartment of PediatricsUniversity of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Ling Li
- Department of EndocrinologyThe Second Affiliated Hospital, Chongqing Medical University, Chongqing, ChinaDpartment of Endocrinology9th People's Hospital of Chongqing, Chongqong, ChinaDepartment of EndocrinologyChongqing Three Gorges Central Hospital, Chongqing, ChinaDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Karolinska University Hospital, Solna, Stockholm, SwedenDepartment of PediatricsUniversity of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Gangyi Yang
- Department of EndocrinologyThe Second Affiliated Hospital, Chongqing Medical University, Chongqing, ChinaDpartment of Endocrinology9th People's Hospital of Chongqing, Chongqong, ChinaDepartment of EndocrinologyChongqing Three Gorges Central Hospital, Chongqing, ChinaDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Karolinska University Hospital, Solna, Stockholm, SwedenDepartment of PediatricsUniversity of Mississippi Medical Center, Jackson, Mississippi, USA
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