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Pérez-Belmonte LM, Osuna-Sánchez J, Ricci M, Millán-Gómez M, López-Carmona MD, Barbancho MA, Bernal-López MR, Jansen-Chaparro S, Lara JP, Gómez-Huelgas R. Management of older hospitalized patients with type 2 diabetes using linagliptin: Lina-Older study. Panminerva Med 2023; 65:13-19. [PMID: 33880897 DOI: 10.23736/s0031-0808.21.04085-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Older patients managed with intensive antidiabetic therapy are more likely to be harmed. Our study's primary endpoint was to analyze the safety and efficacy of linagliptin in combination with basal insulin versus basal-bolus insulin in patients with 75 years of age or older hospitalized in medicine and surgery departments in real-world clinical practice. METHODS We retrospectively enrolled non-critically patients ≥75 years with type 2 diabetes admitted to medicine and non-cardiac surgery departments with admission glycated hemoglobin <8%, admission blood glucose <240 mg/dL, and without at-home injectable therapies managed with our hospital's antihyperglycemic protocol (basal-bolus or linagliptin-basal regimens) between January 2016 and December 2018. To match each patient who started on the basal-bolus regimen with a patient who started on the linagliptin-basal regimen, a propensity matching analysis was used. RESULTS Postmatching, 198 patients were included in each group. There were no significant differences in mean daily blood glucose levels after admission (P=0.203); patients with mean blood glucose 100-140mg/dL (P=0.134), 140-180mg/dL (P=0.109), or >200mg/dL (P=0.299); and number and day of treatment failure (P=0.159 and P=0.175, respectively). The total insulin dose and the number of daily injections were significantly lower in the linagliptin-basal group (both, P<0.001). Patients on the basal-bolus insulin regimen had more total hypoglycemic events than patients on the linagliptin-basal insulin regimen (P<0.001). CONCLUSIONS The linagliptin-basal insulin regimen was an effective alternative with fewer hypoglycemic events and daily insulin injections than intensive basal-bolus insulin in very old patients with type 2 diabetes with mild-to-moderate hyperglycemia treated at home without injectable therapies.
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Affiliation(s)
- Luis M Pérez-Belmonte
- Service of Internal Medicine, Institute of Biomedical Research of Malaga (IBIMA), Regional University Hospital of Malaga, University of Malaga (UMA), Malaga, Spain - .,Service of Internal Medicine, Helicópteros Sanitarios Hospital, Marbella, Spain - .,Center for Biomedical Research in the Cardiovascular Diseases Network (CIBERCV), Carlos III Health Institute, Madrid, Spain - .,Unit of Cognitive Neurophysiology, Faculty of Medicine, Center for Medical Health Research (CIMES), Institute of Biomedical Research of Malaga (IBIMA), University of Malaga (UMA), Malaga, Spain -
| | - Julio Osuna-Sánchez
- Unit of Cognitive Neurophysiology, Faculty of Medicine, Center for Medical Health Research (CIMES), Institute of Biomedical Research of Malaga (IBIMA), University of Malaga (UMA), Malaga, Spain.,Service of Internal Medicine, Hospital Comarcal de La Axarquía, Málaga, Spain
| | - Michele Ricci
- Service of Internal Medicine, Institute of Biomedical Research of Malaga (IBIMA), Regional University Hospital of Malaga, University of Malaga (UMA), Malaga, Spain
| | - Mercedes Millán-Gómez
- Center for Biomedical Research in the Cardiovascular Diseases Network (CIBERCV), Carlos III Health Institute, Madrid, Spain
| | - María D López-Carmona
- Service of Internal Medicine, Institute of Biomedical Research of Malaga (IBIMA), Regional University Hospital of Malaga, University of Malaga (UMA), Malaga, Spain
| | - Miguel A Barbancho
- Unit of Cognitive Neurophysiology, Faculty of Medicine, Center for Medical Health Research (CIMES), Institute of Biomedical Research of Malaga (IBIMA), University of Malaga (UMA), Malaga, Spain
| | - Maria R Bernal-López
- Service of Internal Medicine, Institute of Biomedical Research of Malaga (IBIMA), Regional University Hospital of Malaga, University of Malaga (UMA), Malaga, Spain.,Center for Biomedical Research in Network Physiopathology of Obesity and Nutrition (CIBERobn), Carlos III Health Institute, Madrid, Spain
| | - Sergio Jansen-Chaparro
- Service of Internal Medicine, Institute of Biomedical Research of Malaga (IBIMA), Regional University Hospital of Malaga, University of Malaga (UMA), Malaga, Spain
| | - José P Lara
- Unit of Cognitive Neurophysiology, Faculty of Medicine, Center for Medical Health Research (CIMES), Institute of Biomedical Research of Malaga (IBIMA), University of Malaga (UMA), Malaga, Spain
| | - Ricardo Gómez-Huelgas
- Service of Internal Medicine, Institute of Biomedical Research of Malaga (IBIMA), Regional University Hospital of Malaga, University of Malaga (UMA), Malaga, Spain.,Center for Biomedical Research in Network Physiopathology of Obesity and Nutrition (CIBERobn), Carlos III Health Institute, Madrid, Spain
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Scheen AJ. Efficacy / safety balance of DPP-4 inhibitors versus SGLT2 inhibitors in elderly patients with type 2 diabetes. DIABETES & METABOLISM 2021; 47:101275. [PMID: 34481962 DOI: 10.1016/j.diabet.2021.101275] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 12/14/2022]
Abstract
Dipeptidyl peptidase-4 inhibitors (DPP-4is) and sodium-glucose cotransporter type 2 inhibitors (SGLT2is) offer new options for the oral management of type 2 diabetes mellitus (T2DM), with the advantage in the elderly population to be devoid of a high risk of hypoglycaemia. SGLT2is have also shown benefits regarding cardiovascular (heart failure) and renal protection, including in patients with T2DM aged ≥ 65 years while DPP-4is have only proved cardiovascular and renal safety without superiority compared with placebo. The glucose-lowering efficacy of the two pharmacological classes is almost similar including in older patients with T2DM. However, the tolerance and safety profile may be highly different and overall more favourable with DPP-4is than with SGLT2is. Some adverse events have been reported with SGLT2is which may be more prevalent or severe in older patients than in younger patients. The present comprehensive review focuses on the benefit/risk balance in the elderly population with T2DM by comparing the profile of DPP-4is and SGLT2is regarding the following potential issues: metabolic disorders (hypoglycaemia and diabetic ketoacidosis); cardiac and vascular issues (atheromatous cardiovascular disease, heart failure, volume reduction hypotension, and lower limb amputations); renal endpoints including acute renal injury; risk of infections; digestive disorders; bone and skin adverse events; and cancer risk. Both DPP-4is and SGLT2is have their own advantages and disadvantages. Personalised treatment is recommended based upon the efficacy/safety profile of each drug class and individual patient characteristics that may be markedly different among the heterogeneous population of older individuals with T2DM.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium; Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
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Schernthaner G. Effects of a DPP-4 Inhibitor and RAS Blockade on Clinical Outcomes of Patients with Diabetes and COVID-19 (Diabetes Metab J 2021;45:251-9). Diabetes Metab J 2021; 45:615-616. [PMID: 34352990 PMCID: PMC8369206 DOI: 10.4093/dmj.2021.0081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Guntram Schernthaner
- Department of Medicine, Medical University of Vienna, Vienna, Austria
- Corresponding author: Guntram Schernthaner https://orcid.org/0000-0003-2397-4468 Department of Medicine, Medical University of Vienna, 1180 Währinger Gürtel, Vienna, Austria E-mail:
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Scheen AJ. Careful use to minimize adverse events of oral antidiabetic medications in the elderly. Expert Opin Pharmacother 2021; 22:2149-2165. [PMID: 33823723 DOI: 10.1080/14656566.2021.1912735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION An increasing number of older patients has type 2 diabetes treated with different oral antidiabetic agents whose safety may raise concern considering some particularities of a heterogeneous elderly population. AREAS COVERED This article discusses some characteristics of older patients that could increase the risk of adverse events, with a focus on hypoglycemia. It describes the most frequent and/or severe complications reported in the elderly in both randomized controlled trials and observational studies with metformin, sulfonylureas, meglitinides, alpha-glucosidase inhibitors, thiazolidinediones, dipeptidyl peptidase-4 inhibitors (gliptins) and sodium-glucose cotransporter type 2 inhibitors (gliflozins). EXPERT OPINION Old patients may present comorbidities (renal impairment, vascular disease, heart failure, risk of dehydration, osteoporosis, cognitive dysfunction) that could increase the risk of severe adverse events. Sulfonylureas (and meglitinides) induce hypoglycemia, which may be associated with falls/fractures and cardiovascular events. Medications lacking hypoglycemia should be preferred. Gliptins appear to have the best tolerance/safety profile whereas gliflozins exert a cardiorenal protection. However, data are lacking in very old or frailty old patients so that caution and appropriate supervision of such patients are required. Taking advantage of a large choice of pharmacotherapies, personalized treatment is recommended based upon both drug safety profiles and old patient individual characteristics.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.,Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium
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Cooper ME, Rosenstock J, Kadowaki T, Seino Y, Wanner C, Schnaidt S, Clark D, Johansen OE. Cardiovascular and kidney outcomes of linagliptin treatment in older people with type 2 diabetes and established cardiovascular disease and/or kidney disease: A prespecified subgroup analysis of the randomized, placebo-controlled CARMELINA® trial. Diabetes Obes Metab 2020; 22:1062-1073. [PMID: 32037653 PMCID: PMC7317902 DOI: 10.1111/dom.13995] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/25/2020] [Accepted: 02/06/2020] [Indexed: 12/14/2022]
Abstract
AIMS In CARMELINA®, linagliptin demonstrated cardiovascular and renal safety in patients with type 2 diabetes (T2D) with high renal and cardiovascular disease (CVD) risk. We investigated safety and efficacy of this dipeptidyl peptidase-4 inhibitor in older participants. MATERIALS AND METHODS Subjects aged ≥18 years with T2D and established CVD with urinary albumin-to-creatinine ratio (UACR) >30 mg/g, and/or prevalent kidney disease, were randomized to linagliptin or placebo added to usual care. The primary endpoint (time to first occurrence of 3P-MACE: cardiovascular death, non-fatal myocardial infarction or non-fatal stroke) and other outcomes were evaluated across age groups <65 (n = 2968), 65 to <75 (n = 2800) and ≥75 years (n = 1211). RESULTS Mean age was 65.9 years (17.4% and 5.9% aged ≥75 and 80, respectively) and median follow-up was 2.2 years. The hazard ratio (HR) for 3P-MACE with linagliptin versus placebo was 1.02 [95% confidence interval (CI) 0.89, 1.17] with no significant interaction between age and treatment effect (P = 0.0937). HRs for participants aged <65, 65 to <75 and ≥75 years were 1.11 (95% CI 0.89, 1.40), 1.09 (0.89, 1.33) and 0.76 (0.57, 1.02), respectively. Linagliptin did not increase the risk of adverse kidney outcomes or hospitalization for heart failure across age groups. The incidence of adverse events, including hypoglycaemia, increased with age but was similar with linagliptin and placebo despite glycated haemoglobin A1c reduction with linagliptin. CONCLUSIONS Linagliptin did not increase risk for cardiovascular events or hypoglycaemia and kidney function remained stable in older people with T2D and established CVD with albuminuria and/or kidney disease.
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Affiliation(s)
- Mark E. Cooper
- Department of Diabetes, Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
| | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical CityDallasTexas
- University of Texas, Southwestern Medical CenterDallasTexas
| | - Takashi Kadowaki
- Department of Prevention of Diabetes and Lifestyle‐related Diseases, Graduate School of MedicineUniversity of TokyoTokyoJapan
- Department of Metabolism and Nutrition, Mizonokuchi Hospital, Faculty of MedicineTeikyo UniversityKanagawaJapan
| | - Yutaka Seino
- Kansai Electric Power Medical Research InstituteOsakaJapan
- Center for Diabetes, Endocrinology and Metabolism, Kansai Electric Power HospitalOsakaJapan
| | - Christoph Wanner
- Division of Nephrology, Department of MedicineWürzburg University ClinicWürzburgGermany
| | - Sven Schnaidt
- Boehringer Ingelheim Pharma GmbH & Co KGBiberachGermany
| | - Douglas Clark
- Boehringer Ingelheim International GmbH, IngelheimGermany
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Hoogwerf BJ, MacKenzie M, Sealls W, Cordova J, Gandhi P. Real-World Glycemic Lowering Effectiveness of Linagliptin Among Adults with Type 2 Diabetes by Age, Renal Function, and Race. Diabetes Ther 2020; 11:1527-1536. [PMID: 32462538 PMCID: PMC7324460 DOI: 10.1007/s13300-020-00841-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION To assess real-world effectiveness of linagliptin in persons with type 2 diabetes mellitus (T2DM) across a range of ages and renal function. Effectiveness was assessed in different races, with a focus on African Americans (AA). METHODS This was a non-interventional retrospective cohort study using data in the Optum clinical database from adults with T2DM initiating linagliptin. Date of the first linagliptin prescription was the index date. Outcomes included change in glycated hemoglobin (HbA1c) and the percentage of persons achieving an HbA1c < 7% (53 mmol/mol) during the 60-180 days following linagliptin initiation. Analyses of age by renal function were conducted. Multivariate regression analysis was performed to assess change in HbA1c, controlling for an a priori list of covariates. RESULTS Overall, 11,001 persons were included. Mean pre-index HbA1c value was 8.2% (66 mmol/mol), with higher levels in younger versus older persons and AAs versus other race groups. Persons initiating linagliptin had an average HbA1c reduction of 0.51% (5.6 mmol/mol). Without adjusting for age, renal function, race, and pre-index HbA1c, greater reductions in HbA1c were observed in younger versus older persons, persons with higher versus lower estimated glomerular filtration rate (eGFR), and AAs versus white or Asians. After multivariate analysis, variables significantly associated with a greater HbA1c reduction included higher pre-index HbA1c and older age. CONCLUSIONS These results support the HbA1c-lowering effectiveness of linagliptin across age, race, and renal function categories among a large real-world population of adults with T2DM.
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Affiliation(s)
| | | | | | - Jeanine Cordova
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Pranav Gandhi
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
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Dedov II, Shestakova MV, Mayorov AY, Shamkhalova MS, Sukhareva OY, Galstyan GR, Tokmakova AY, Nikonova TV, Surkova EV, Kononenko IV, Egorova DN, Ibragimova LI, Shestakova EA, Klefortova II, Sklyanik IA, Yarek-Martynova IY, Severina AS, Martynov SA, Vikulova OK, Kalashnikov VY, Bondarenko IZ, Gomova IS, Starostina EG, Ametov AS, Antsiferov MB, Bardymova TP, Bondar IA, Valeeva FV, Demidova TY, Mkrtumyan AM, Petunina NA, Ruyatkina LA, Suplotova LA, Ushakova OV, Khalimov YS. Diabetes mellitus type 2 in adults. DIABETES MELLITUS 2020. [DOI: 10.14341/dm12507] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Tatiana P. Bardymova
- Irkutsk State Medical Academy of Postgraduate Education – Branch Campus of the Russian Medical Academy of Continuing Professional Education
| | | | | | | | - Ashot M. Mkrtumyan
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov
| | - Nina A. Petunina
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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Lapolla A, Genovese S, Giorgino F, Disoteo O, Sartore G, Bartezaghi M, Del Prato S. Patient-reported outcomes in elderly patients with type 2 diabetes mellitus treated with dual oral therapy: a multicenter, observational study from Italy. Curr Med Res Opin 2020; 36:555-562. [PMID: 31868033 DOI: 10.1080/03007995.2019.1707649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To assess patient-reported outcomes after two years of use of dual oral anti-diabetes drug (OAD) therapy in elderly people (≥65 years) with type 2 diabetes mellitus (T2DM) from Italy under real-life settings.Methods: 3-AGE was a prospective, non-interventional study in elderly people with T2DM inadequately controlled on metformin monotherapy (defined as glycated hemoglobin [HbA1c] 7.0-9.0%), in whom a second OAD was prescribed. Primary endpoint was to assess the physical and psychological symptoms associated with T2DM from baseline to 24 months using the Diabetes Symptom Check List revised (DSC-R) questionnaire. Patient's quality of life and health status, treatment satisfaction, consumption of healthcare resources, and physician satisfaction with treatment were also assessed (secondary endpoints) using validated questionnaires. Additionally, safety and clinical characteristics were also evaluated.Results: The mean age of the study population (N = 860) was 71.5 ± 5.2 years. Addition of a second OAD significantly (p < .0001) reduced the DSC-R score from baseline (0.73 ± 0.68) to both Months 12 and 24 (0.63 ± 0.59 and 0.61 ± 0.56), and HbA1c from baseline (7.72% ± 0.54%) to Month 12 (6.95% ± 0.82%). Adding a second OAD improved quality of life and health status (baseline, 71.31 ± 15.16 to Month 12, 74.49 ± 13.64; p < .0001), patient's treatment satisfaction (p < .0001), and consumption of healthcare resources per patient. Physicians expressed good satisfaction with patients' treatment (across efficacy, tolerability and compliance domains) at Month 12. Overall, 32 adverse reactions (in 24 patients) and four hypoglycemic episodes were reported during the 24 months.Conclusion: Addition of a second OAD improved physical and psychological symptoms associated with T2DM and was well tolerated in elderly people under real-life settings.
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Affiliation(s)
| | - Stefano Genovese
- Diabetes, Endocrine and Metabolic Diseases Unit, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Francesco Giorgino
- Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Olga Disoteo
- Diabetes Unit, Niguarda Cà Granda Hospital, Milan, Italy
| | | | | | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Ledesma G, Umpierrez GE, Morley JE, Lewis-D'Agostino D, Keller A, Meinicke T, van der Walt S, von Eynatten M. Efficacy and safety of linagliptin to improve glucose control in older people with type 2 diabetes on stable insulin therapy: A randomized trial. Diabetes Obes Metab 2019; 21:2465-2473. [PMID: 31297968 DOI: 10.1111/dom.13829] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/25/2019] [Accepted: 07/07/2019] [Indexed: 12/30/2022]
Abstract
AIM To assess the addition of linagliptin as an alternative to insulin uptitration in older people with type 2 diabetes on stable insulin therapy. MATERIALS AND METHODS This phase 4, randomized, multicentre, double-blinded, placebo-controlled, 24-week study recruited individuals on stable insulin, with baseline HbA1c 7.0%-10.0%, aged ≥60 years and body mass index ≤45 kg/m2 . HbA1c and fasting plasma glucose were measured at study visits, and participants assessed glycaemic control with a self-monitoring blood glucose device. Adverse events (AEs) were reported during the study. RESULTS Three hundred and two participants were randomized 1:1 to linagliptin 5 mg qd and placebo, with one third of patients from Japan. Study population age and HbA1c (baseline mean ± SD) were 72.4 ± 5.4 years and 8.2 ± 0.8%, respectively; ~80% of participants were aged ≥70 years; 80% had macrovascular complications, one third had a baseline estimated glomerular filtration rate <60 mL/min/1.73 m2 ; and half had been diagnosed with diabetes for >15 years. Linagliptin significantly improved glucose control at 24 weeks (HbA1c-adjusted mean change vs. placebo: -0.63%; P <0.0001) and the probability of achieving predefined HbA1c targets without hypoglycaemia (HbA1c <8.0%: OR 2.02; P <0.05 and HbA1c <7.0%: OR 2.44; P <0.01). Linagliptin versus placebo was well tolerated, with similar incidences of AEs, including clinically important hypoglycaemia (blood glucose <54 mg/dL) or severe hypoglycaemia. CONCLUSIONS Addition of linagliptin improves glucose control without an excess of hypoglycaemia in older patients with type 2 diabetes on stable insulin therapy.
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Affiliation(s)
| | | | - John E Morley
- Division of Geriatric Medicine, Saint Louis University, St. Louis, Missouri
| | | | - Annett Keller
- Global BDS, Boehringer Ingelheim Pharma GmbH & Co, KG, Ingelheim, Germany
| | - Thomas Meinicke
- TA CardioMetabolism, Boehringer Ingelheim International GmbH, Biberach, Germany
| | - Sandra van der Walt
- International Project Management Cardiometabolic/CNS, Boehringer Ingelheim International GmbH, Ingelheim, Germany
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Long-Term Efficacy and Safety of Linagliptin in a Japanese Population with Type 2 Diabetes Aged ≥ 60 Years Treated with Basal Insulin: A Randomised Trial. Adv Ther 2019; 36:2697-2711. [PMID: 31482511 PMCID: PMC6822821 DOI: 10.1007/s12325-019-01065-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Indexed: 01/21/2023]
Abstract
INTRODUCTION An estimated 4.3 million people aged ≥ 65 years with diabetes live in Japan. We evaluated the efficacy and safety of linagliptin in older Japanese patients with poorly controlled type 2 diabetes (T2DM). METHODS In this phase 4, randomised, placebo-controlled national study (part of a global study) conducted in Japan over a period of 52 weeks, 102 patients on stable treatment with basal insulin ± metformin/alpha-glucosidase inhibitors were randomised (1:1) to receive linagliptin 5 mg qd or placebo. The primary end point was the change in glycated haemoglobin (HbA1c) after 24 weeks of treatment, with additional analyses at 52 weeks. RESULTS Mean age and HbA1c of the study population were 71 years and 8.1%, respectively. Approximately two-thirds of participants were aged ≥ 70 years, two-thirds had macrovascular complications, approximately half had a baseline estimated glomerular filtration rate < 60 ml/min/1.73 m2, and two-thirds had a time since diagnosis of diabetes > 10 years. Significant HbA1c reductions with linagliptin vs. placebo were observed at 24 weeks, - 0.71% (95% CI - 0.96, - 0.45, p < 0.0001), and maintained at 52 weeks, - 0.58% (95% CI - 0.82, - 0.34, p < 0.0001). Linagliptin improved the chances of achieving a categorical HbA1c target (< 8.0% and < 7.0%) at 24 and 52 weeks in patients who were not at their respective target at the beginning of the study. Addition of linagliptin to insulin was associated with a numerical increase in the risk of any hypoglycaemia, but not in the risk of clinically significant hypoglycaemia, severe hypoglycaemia or recurring hypoglycaemia. CONCLUSION Linagliptin was effective in improving glucose control in Japanese patients aged ≥ 60 years with T2DM on stable glucose-lowering therapy with basal insulin. Linagliptin was well tolerated and no new safety concerns were raised. The results presented here are highly consistent with the results from the global study, which was conducted over a 24-week period. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02240680. FUNDING Boehringer Ingelheim and Eli Lilly and Company Diabetes Alliance.
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Nauck M, Araki A, Hehnke U, Plat A, Clark D, Khunti K. Risk of hypoglycaemia in people aged ≥65 years receiving linagliptin: pooled data from 1489 individuals with type 2 diabetes mellitus. Int J Clin Pract 2018; 72:e13240. [PMID: 30216648 DOI: 10.1111/ijcp.13240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/03/2018] [Indexed: 12/21/2022] Open
Abstract
AIMS To investigate the risk of hypoglycaemia in people aged ≥65 years with type 2 diabetes mellitus (T2DM) treated with linagliptin, in the largest pooled analysis performed to date. MATERIALS AND METHODS One thousand four hundred and eighty-nine patients aged ≥65 years with T2DM were pooled from 11 randomised, double-blind, parallel group, placebo-controlled trials evaluating linagliptin 5 mg alone, or in addition to various background therapies. The primary safety endpoint was the incidence of investigator-defined hypoglycaemia. RESULTS There was no significant difference in the risk of hypoglycaemia between linagliptin and placebo in the all-patient population at 24 weeks (hazard ratio [HR] 1.07; 95% confidence interval [CI]: 0.84, 1.36; P = 0.5943)-despite significant (P < 0.0001) improvements in glycaemic control-and 1 year (HR 1.02; 95% CI: 0.81, 1.27; P = 0.8803). Similar findings were observed for linagliptin vs placebo in subgroup analyses by background medication (eg, sulphonylureas (SUs) and/or insulin vs no such drugs), age, baseline glycated haemoglobin (HbA1c), ethnicity, and baseline estimated glomerular filtration rate. Patients with a baseline HbA1c ≥7.5% had significantly higher odds of achieving HbA1c <7.5% without hypoglycaemia in the linagliptin group compared with placebo at 24 weeks (34.1% vs 13.7%; 95% CI: 2.04, 4.12; P < 0.0001). CONCLUSIONS This pooled analysis indicates that linagliptin was effective in treating older people with T2DM towards their HbA1c targets with a favourable safety and tolerability profile and low risk of hypoglycaemia. The safety profile was maintained even on background therapies with known risk of hypoglycaemia, such as insulin and SU.
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Affiliation(s)
- Michael Nauck
- Diabetes Center Bochum-Hattingen, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | | | - Uwe Hehnke
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Arian Plat
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Eli Lilly and Company, Utrecht, Netherlands
| | - Douglas Clark
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
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Meneilly GS, Knip A, Miller DB, Sherifali D, Tessier D, Zahedi A. Diabetes in Older People. Can J Diabetes 2018; 42 Suppl 1:S283-S295. [PMID: 29650107 DOI: 10.1016/j.jcjd.2017.10.021] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 12/15/2022]
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Farngren J, Persson M, Ahrén B. Effects on the glucagon response to hypoglycaemia during DPP-4 inhibition in elderly subjects with type 2 diabetes: A randomized, placebo-controlled study. Diabetes Obes Metab 2018; 20:1911-1920. [PMID: 29645341 DOI: 10.1111/dom.13316] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/28/2018] [Accepted: 04/01/2018] [Indexed: 12/19/2022]
Abstract
AIMS Maintainance of glucagon response to hypoglycaemia is important as a safeguard against hypoglycaemia during glucose-lowering therapy in type 2 diabetes. During recent years, DPP-4 (dipeptidyl peptidase-4) inhibition has become more commonly used in elderly patients. However, whether DPP-4 inhibition affects the glucagon response to hypoglycaemia in the elderly is not known and was the aim of this study. METHODS In a single-centre, double-blind, randomized, placebo-controlled crossover study, 28 subjects with metformin-treated type 2 diabetes (17 male, 11 female; mean age, 74 years [range 65-86]; mean HbA1c, 51.5 mmol/mol [6.9%]) received sitagliptin (100 mg once daily) as add-on therapy or placebo for 4 weeks with a 4-week washout period in between. After each treatment period, the subjects underwent a standard breakfast test, followed by a 2-step hyperinsulinaemic hypoglycaemic clamp (target 3.5 and 3.0 mmol/L), followed by lunch. RESULTS Glucagon levels after breakfast and lunch, and the glucagon response at 3.5 mmol/L, were lower after sitagliptin than after placebo. However, the glucagon response to hypoglycaemia at 3.1 mmol/L did not differ significantly between the two. Similarly, the noradrenaline, adrenaline and cortisol responses were lower with sitagliptin than with placebo at 3.5 mmol/L, but not at 3.1 mmol/L glucose. Responses in pancreatic polypeptide did not differ between the two. CONCLUSIONS Elderly subjects with metformin-treated type 2 diabetes have lower glucagon levels at 3.5 mmol/L glucose, but maintain the glucagon response to hypoglycaemia at 3.1 mmol/L during DPP-4 inhibition, which safeguards against hypoglycaemia and may contribute to decreasing the risk of hypoglycaemia by DPP-4 inhibition in this age group.
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Affiliation(s)
- Johan Farngren
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | | | - Bo Ahrén
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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Overbeek JA, Bakker M, van der Heijden AAWA, van Herk-Sukel MPP, Herings RMC, Nijpels G. Risk of dipeptidyl peptidase-4 (DPP-4) inhibitors on site-specific cancer: A systematic review and meta-analysis. Diabetes Metab Res Rev 2018; 34:e3004. [PMID: 29573125 DOI: 10.1002/dmrr.3004] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 01/03/2018] [Accepted: 03/12/2018] [Indexed: 12/19/2022]
Abstract
The long-term impact of dipeptidyl peptidase-4 (DPP-4) inhibition is unknown, and there are concerns about the influence of DPP-4 inhibition on carcinogenesis of the pancreas and thyroid. As DPP-4 is a rather unselective enzyme present in many tissues, we focused on all specific cancer types. PubMed and EMBASE were searched between January 2005 and April 2017 to identify studies comparing DPP-4 inhibitors with either placebo or active drugs on cancer risk. Studies were included if they reported on at least one specific cancer outcome and had a follow-up of at least 1 year after start of drug use. Methodological quality of the studies was assessed by the Cochrane Collaboration's tool and the Newcastle-Ottawa Scale. Twenty-five studies met the inclusion criteria (12 randomized controlled trials and 13 observational studies). Sample sizes of the DPP-4 inhibitor groups ranged from 29 to 8212 patients for randomized controlled trials and from 2422 to 71 137 patients for observational studies. Mean age ranged from 51 to 76 years, and mean follow-up was 1.5 years. None of the pooled (sensitivity) analyses, except the observational studies studying breast cancer (hazard ratio [95% CI]: 0.76 [0.60-0.96]), showed evidence for an association between DPP-4 inhibitors and site-specific cancer. Also for pancreatic and thyroid cancer, no statistically significant risk was found. Based on the current literature, it is not possible to conclude whether DPP-4 inhibitors were associated with an increased risk of site-specific cancer. Future studies should address the methodological limitations and follow patients for a longer period to determine the long-term cancer risk of DPP-4 inhibitors.
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Affiliation(s)
- Jetty A Overbeek
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, Netherlands
- PHARMO Institute for Drug Outcomes Research, Utrecht, Netherlands
| | - Marina Bakker
- PHARMO Institute for Drug Outcomes Research, Utrecht, Netherlands
| | - Amber A W A van der Heijden
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, Netherlands
| | - Myrthe P P van Herk-Sukel
- Department of Internal Medicine and Dermatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ron M C Herings
- PHARMO Institute for Drug Outcomes Research, Utrecht, Netherlands
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, Netherlands
| | - Giel Nijpels
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Centre, Amsterdam, Netherlands
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15
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Umpierrez GE, Cardona S, Chachkhiani D, Fayfman M, Saiyed S, Wang H, Vellanki P, Haw JS, Olson DE, Pasquel FJ, Johnson TM. A Randomized Controlled Study Comparing a DPP4 Inhibitor (Linagliptin) and Basal Insulin (Glargine) in Patients With Type 2 Diabetes in Long-term Care and Skilled Nursing Facilities: Linagliptin-LTC Trial. J Am Med Dir Assoc 2018; 19:399-404.e3. [PMID: 29289540 PMCID: PMC6093296 DOI: 10.1016/j.jamda.2017.11.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 11/01/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Safe and easily implemented treatment regimens are needed for the management of patients with type 2 diabetes mellitus (T2DM) in long-term care (LTC) and skilled nursing facilities. DESIGN This 6-month open-label randomized controlled trial compared the efficacy and safety of a DPP4 inhibitor (linagliptin) and basal insulin (glargine) in LTC residents with T2DM. SETTINGS Three LTC institutions affiliated with a community safety-net hospital, US Department of Veterans Affairs and Emory Healthcare System in Atlanta, Georgia. PARTICIPANTS A total of 140 residents with T2DM treated with oral antidiabetic agents or low-dose insulin (≤0.1 U/kg/d), with fasting or premeal blood glucose (BG) > 180 mg/dL and/or HbA1c >7.5%. INTERVENTION Baseline antidiabetic therapy, except metformin, was discontinued on trial entry. Residents were treated with linagliptin 5 mg/d (n = 67) or glargine at a starting dose of 0.1 U/kg/d (n = 73). Both groups received supplemental rapid-acting insulin before meals for BG > 200 mg/dL. MEASUREMENTS Primary outcome was mean difference in daily BG between groups. Main secondary endpoints included differences in frequency of hypoglycemia, glycosylated hemoglobin (HbA1c), complications, emergency department visits, and hospital transfers. RESULTS Treatment with linagliptin resulted in no significant differences in mean daily BG (146 ± 34 mg/dL vs. 157 ± 36 mg/dL, P = .07) compared to glargine. Linagliptin treatment resulted in fewer mild hypoglycemic events <70 mg/dL (3% vs. 37%, P < .001), but there were no differences in BG < 54 mg/dL (P = .06) or <40 mg/dL (P = .05) compared to glargine. There were no significant between-group differences in HbA1c, length of stay, complications, emergency department visits, or hospitalizations. CONCLUSION Treatment with linagliptin resulted in noninferior glycemic control and in significantly lower risk of hypoglycemia compared to insulin glargine in long-term care and skilled nursing facility residents with type 2 diabetes.
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Affiliation(s)
| | | | | | - Maya Fayfman
- Department of Medicine, Emory University, Atlanta, GA
| | - Sahebi Saiyed
- Department of Medicine, Emory University, Atlanta, GA
| | - Heqiong Wang
- Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - J Sonya Haw
- Department of Medicine, Emory University, Atlanta, GA
| | - Darin E Olson
- Department of Medicine, Emory University, Atlanta, GA
| | | | - Theodore M Johnson
- Department of Medicine, Emory University, Atlanta, GA; Birmingham/Atlanta VA GRECC
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17
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Gómez-Huelgas R, Gómez Peralta F, Rodríguez Mañas L, Formiga F, Puig Domingo M, Mediavilla Bravo JJ, Miranda C, Ena J. [Treatment of type 2 diabetes mellitus in elderly patients]. Rev Esp Geriatr Gerontol 2018; 53:89-99. [PMID: 29439834 DOI: 10.1016/j.regg.2017.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 06/08/2023]
Abstract
The prevalence of type 2 diabetes mellitus (DM2) increases markedly with age. Antidiabetic treatment and the objectives of glycaemic control in elderly patients with DM2 should be individualised according to their biopsychosocial characteristics. In elderly patients for whom the benefits of intensive antidiabetic treatment are limited, the basic objectives should be to improve the quality of life, preserve functionality and avoid adverse effects, especially hypoglycaemia. Treatment of DM2 in the elderly was the subject of a consensus document published in 2012 and endorsed by several Spanish scientific societies. Since then, new therapeutic groups and evidence have emerged that warrant an update to this consensus document. The present document focuses on the therapeutic aspects of DM2 in elderly patients, understood as being older than 75 years or frail.
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Affiliation(s)
- R Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA); CIBER de Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III; Sociedad Española de Medicina Interna (SEMI).
| | - F Gómez Peralta
- Unidad de Endocrinología y Nutrición, Hospital General de Segovia, Segovia, España; Sociedad Española de Diabetes (SED)
| | - L Rodríguez Mañas
- Servicio de Geriatría, Hospital Universitario de Getafe, Madrid, España; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III; Sociedad Española de Medicina Geriátrica (SEMEG)
| | - F Formiga
- Unidad de Geriatría, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España; Sociedad Española de Geriatría y Gerontología (SEGG)
| | - M Puig Domingo
- Servicio de Endocrinología y Nutrición, Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, España; CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III; Sociedad Española de Endocrinología y Nutrición (SEEN)
| | - J J Mediavilla Bravo
- Centro de Salud Burgos Rural, Burgos, España; Sociedad Española de Medicina General (SEMERGEN)
| | - C Miranda
- Centro de Salud Buenavista, Toledo, España; Sociedad Española de Médicos Generales y de Familia (SEMG)
| | - J Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, La Vila Joiosa, Alicante, España; Sociedad Española de Medicina Interna (SEMI)
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Gómez-Huelgas R, Gómez Peralta F, Rodríguez Mañas L, Formiga F, Puig Domingo M, Mediavilla Bravo JJ, Miranda C, Ena J. Treatment of type 2 diabetes mellitus in elderly patients. Rev Clin Esp 2018; 218:74-88. [PMID: 29366502 DOI: 10.1016/j.rce.2017.12.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/03/2017] [Indexed: 02/06/2023]
Abstract
The prevalence of type 2 diabetes mellitus (DM2) increases markedly with age. Antidiabetic treatment and the objectives of glycaemic control in elderly patients with DM2 should be individualised according to their biopsychosocial characteristics. In elderly patients for whom the benefits of intensive antidiabetic treatment are limited, the basic objectives should be to improve the quality of life, preserve functionality and avoid adverse effects, especially hypoglycaemia. Treatment of DM2 in the elderly was the subject of a consensus document published in 2012 and endorsed by several Spanish scientific societies. Since then, new therapeutic groups and evidence have emerged that warrant an update to this consensus document. The present document focuses on the therapeutic aspects of DM2 in elderly patients, understood as being older than 75 years or frail.
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Affiliation(s)
- R Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA); CIBER de Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III; Sociedad Española de Medicina Interna (SEMI).
| | - F Gómez Peralta
- Unidad de Endocrinología y Nutrición, Hospital General de Segovia, Segovia, España; Sociedad Española de Diabetes (SED)
| | - L Rodríguez Mañas
- Servicio de Geriatría, Hospital Universitario de Getafe, Madrid, España; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III; Sociedad Española de Medicina Geriátrica (SEMEG)
| | - F Formiga
- Unidad de Geriatría, Hospital Universitari de Bellvitge, ĹHospitalet de Llobregat, Barcelona, España; Sociedad Española de Geriatría y Gerontología (SEGG)
| | - M Puig Domingo
- Servicio de Endocrinología y Nutrición, Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, España; CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III; Sociedad Española de Endocrinología y Nutrición (SEEN)
| | - J J Mediavilla Bravo
- Centro de Salud Burgos Rural, Burgos, España; Sociedad Española de Medicina General (SEMERGEN)
| | - C Miranda
- Centro de Salud Buenavista, Toledo, España; Sociedad Española de Médicos Generales y de Familia (SEMG)
| | - J Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, La Vila Joiosa, Alicante, España; Sociedad Española de Medicina Interna (SEMI)
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Chen H, Zhou X, Chen T, Liu B, Jin W, Gu H, Hong T, Zhang G. Incretin-Based Therapy and Risk of Pancreatic Cancer in Patients with Type 2 Diabetes Mellitus: A Meta-analysis of Randomized Controlled Trials. Diabetes Ther 2016; 7:725-742. [PMID: 27655330 PMCID: PMC5118236 DOI: 10.1007/s13300-016-0198-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION The present study aims to evaluate the risk of pancreatic cancer with incretin-based therapy among patients with type 2 diabetes mellitus (T2DM). METHODS We searched EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov for eligible studies published up to March 06 2016. This meta-analysis includes all studies reporting adverse events of pancreatic cancer with use of incretin-based therapies compared with placebo or non-incretin anti-diabetic drugs in patients with T2DM. We used fixed-effect model to compare pooled relative risk (RR) with related 95% confidence intervals (CI). RESULTS A total of 159 randomized trials were identified. Out of these, 135 studies were excluded as pancreatic cancer occurrence had not been included as an end point. The remaining 24 trials enrolling 47,904 participants were further assessed. Overall, no increased risk of pancreatic cancer were detected in association with incretin-based treatment (RR = 0.7, 95% CI 0.37-1.05). The incidence of pancreatic neoplasm was even lower among incretin-based groups than controls (RR = 0.50, 95% CI 0.29-0.87) in trials with duration more than 104 weeks. There was even decreased risk of pancreatic cancer within groups paralleled by incretin-matched placebos (RR = 0.55, 95% CI 0.32-0.93) than by non-incretin anti-diabetic drugs. Neither monotherapy (RR = 0.62, 95% CI 0.38-1.01) nor combination regimen (RR = 0.92, 95% CI 0.45-1.90) of incretin mimetics increased the risk of pancreatic cancer. CONCLUSION This meta-analysis shows that incretin-based therapies are not associated with increase in the risk of pancreatic cancer. Interestingly, subgroup analyses suggested lower risk of pancreatic cancer in incretin groups than placebo in long-term studies (>104 weeks). Considering the inconsistent results among randomized trials and previous epidemiological investigations, more such studies should be conducted to clarify the existence or non-existence of this association. FUNDING This work was supported by grants from the National Natural Science Foundation of China (Nos. 81270476 and 81470830).
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Affiliation(s)
- Han Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
- First Clinical Medical College of Nanjing Medical University, Nanjing, 210029, China
| | - Xiaoying Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
- First Clinical Medical College of Nanjing Medical University, Nanjing, 210029, China
| | - Tao Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
- First Clinical Medical College of Nanjing Medical University, Nanjing, 210029, China
| | - Bingtuan Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
- First Clinical Medical College of Nanjing Medical University, Nanjing, 210029, China
| | - Wujuan Jin
- Department of Gastroenterology, Sir Yifu Hospital Affiliated with Nanjing Medical University, Nanjing, 210029, China
| | - Huiyuan Gu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Tianyuan Hong
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
- First Clinical Medical College of Nanjing Medical University, Nanjing, 210029, China
| | - Guoxin Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
- First Clinical Medical College of Nanjing Medical University, Nanjing, 210029, China.
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Lehrke M, Leiter LA, Hehnke U, Thiemann S, Bhandari A, Meinicke T, Johansen OE. Safety and efficacy of linagliptin in patients with type 2 diabetes mellitus and coronary artery disease: Analysis of pooled events from 19 clinical trials. J Diabetes Complications 2016; 30:1378-84. [PMID: 27396241 DOI: 10.1016/j.jdiacomp.2016.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/13/2016] [Accepted: 06/15/2016] [Indexed: 12/15/2022]
Abstract
AIMS To examine the safety and efficacy of linagliptin in patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) using pooled data from the global clinical trials program. METHODS Patient-level data were pooled from randomized, placebo-controlled clinical trials of linagliptin (5mg, monotherapy or combination therapy). Safety/efficacy analyses were conducted for patients with CAD and ≥12 and ≥24weeks of treatment, respectively. RESULTS The safety analysis included 19 trials (linagliptin, n=451; placebo, n=272) and the efficacy analysis, 12 trials (linagliptin, n=328; placebo, n=198); mean (± standard deviation) exposure to study treatment was 212 (144) days linagliptin and 245 (171) days placebo. Occurrence of cardiac adverse events (AEs) was similar for linagliptin- and placebo-treated patients (9.1% and 9.2%, respectively); exposure-adjusted incidence rates (per 100 patient-years) were 16.6 and 14.0, respectively. Overall incidence of AEs was numerically lower with linagliptin than placebo. After 24weeks, mean adjusted change (standard error) from baseline glycosylated hemoglobin was -0.64% (0.04) with linagliptin vs. -0.08% (0.05) with placebo (P<.001). CONCLUSIONS This comprehensive pooled analysis showed that addition of linagliptin to treatment regimens of patients with T2DM and CAD was not associated with an increased incidence of cardiac AEs, was well tolerated, and was effective.
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Affiliation(s)
| | - Lawrence A Leiter
- Keenan Research Centre in the Li Ka Shing Research Institute, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Uwe Hehnke
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Sandra Thiemann
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Amit Bhandari
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
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Schernthaner G, Schernthaner-Reiter MH, Schernthaner GH. EMPA-REG and Other Cardiovascular Outcome Trials of Glucose-lowering Agents: Implications for Future Treatment Strategies in Type 2 Diabetes Mellitus. Clin Ther 2016; 38:1288-1298. [PMID: 27210264 DOI: 10.1016/j.clinthera.2016.04.037] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 02/07/2023]
Abstract
During the last decade, the armamentarium for glucose-lowering drugs has increased enormously by the development of DPP-4 inhibitors, GLP-1 receptor agonists and SGLT2 inhibitors, allowing individualization of antidiabetic therapy for patients with type 2 diabetes (T2DM). Some combinations can now be used without an increased risk for severe hypoglycemia and weight gain. Following a request of the US Food and Drug Administration, many large cardiovascular (CV) outcome studies have been performed in patients with longstanding disease and established CV disease. In the majority of CV outcome studies, CV risk factors were well controlled and a high number of patients were already treated with ACE inhibitors/angiotensin receptor blockers, statins and antiplatelet drugs. Most studies with insulin glargine and newer glucose-lowering drugs (saxagliptin, alogliptin, sitagliptin, lixisenatide) demonstrated safety of newer glucose-lowering agents but did not show superiority in the CV outcomes compared with placebo. By contrast, in the EMPA-REG OUTCOME (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients) study, CV death, all-cause mortality, and hospitalization for heart failure were significantly decreased when empagliflozin was added instead of placebo to therapy for patients with high CV risk and T2DM already well treated with statins, glucose-lowering drugs, and blood pressure-lowering drugs as well as antiplatelet agents. In addition, renal endpoints including endstage renal disease were also significantly reduced when empagliflozin was added instead of placebo. Interestingly, the reduction of these clinically relevant end points was observed after a few months, making antiatherogenic effects an unlikely cause. The fact that the incidence of myocardial infarction (MI) and stroke were not reduced is in line with the hypothesis that hemodynamic factors in particular have contributed to the impressive improvement of the prognosis. To reduce the CV burden of patients with T2DM, drugs influencing factors involved in atherogenesis (eg, insulin resistance, chronic inflammation, increase of HDL, prothrombotic state) are more promising. The recent IRIS (Insulin Resistance Intervention after Stroke) study documented a significant reduction in stroke and MI when pioglitazone instead of placebo was given to nondiabetic patients presenting with both stroke/transient ischemic attack and insulin resistance, confirming results from the PROactive (Prospective Pioglitazone Clinical Trial in Macrovascular Events) study in patients with T2DM. Based on these new data, we suggest that the addition of both empagliflozin and pioglitazone to metformin might be the relative best option to reduce the high CV morbidity and mortality of patients with T2DM and already established CV complications. The very recent announcement that the CV outcome study with liraglutide (LEADER) also demonstrated a significant reduction of the composite endpoint (cardiovascular death, non-fatal myocardial infarction or non-fatal stroke) gives new hope for further beneficial treatment options for T2DM patients with established CVD.
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Abstract
Prevention of cardiovascular morbidity and mortality remains the key factor in the treatment of type 2 diabetes (T2DM). In the early phase of T2DM, multifactorial intervention is mandatory and glucose levels should be near normal, in particular in younger patients presenting with the highest cardiovascular risk. Anti-diabetic drugs without any risk for hypoglycaemia should be preferred in order to reduce clinical inertia and increase the long-term adherence to the treatment. In patients already presenting with cardiovascular disease, the best outcome may be expected with the triple oral therapy of metformin, pioglitazone, and empagliflozin, although a controlled prospective study versus insulin therapy is needed to confirm the expectation.
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Affiliation(s)
| | - G-H Schernthaner
- Department of Medicine II, Division of Angiology, Medical University Vienna, Wien, Österreich
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Penno G, Garofolo M, Del Prato S. Dipeptidyl peptidase-4 inhibition in chronic kidney disease and potential for protection against diabetes-related renal injury. Nutr Metab Cardiovasc Dis 2016; 26:361-373. [PMID: 27105869 DOI: 10.1016/j.numecd.2016.01.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 12/21/2015] [Accepted: 01/07/2016] [Indexed: 02/06/2023]
Abstract
AIMS Type 2 diabetes mellitus (T2DM) is associated with a high risk of chronic kidney disease (CKD). About 20% of patients with T2DM have CKD of stage ≥ 3; up to 40% have some degree of CKD. Beyond targeting all renal risk factors together, renin-angiotensin-aldosterone system blockers are to date the only effective mainstay for the treatment of diabetic kidney disease (DKD). Indeed, several potentially nephroprotective agents have been in use, which have been unsuccessful. Some glucose-lowering agents, including dipeptidyl peptidase-4 inhibitors (DPP-4i), have shown promising results. Here, we discuss the evidence that glucose lowering with DPP-4i may be an option for protecting against diabetes-related renal injury. DATA SYNTHESIS A comprehensive search was performed of the literature using the terms "alogliptin," "linagliptin," "saxagliptin," "sitagliptin," and "vildagliptin" for original articles and reviews addressing this topic. DPP-4i are an effective, well-tolerated treatment option for T2DM with any degree of renal impairment. Preclinical observations and clinical studies suggest that DPP-4i might also be a promising strategy for the treatment of DKD. The available data are in favor of saxagliptin and linagliptin, but the consistency of results points to the possible nephroprotective effect of DPP-4i. This property appears to be independent of glucose lowering and can potentially complement other therapies that preserve renal function. Larger prospective clinical trials are ongoing, which might strengthen these hypothesis-generating findings. CONCLUSIONS The improvement in albuminuria associated with DPP-4i suggests that these agents may provide renal benefits beyond their glucose-lowering effects, thus offering direct protection from DKD. These promising results must be interpreted with caution and need to be confirmed in forthcoming studies.
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Affiliation(s)
- G Penno
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy.
| | - M Garofolo
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - S Del Prato
- Section of Diabetes and Metabolic Disease, Department of Clinical and Experimental Medicine, University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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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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Formiga F, Gómez-Huelgas R, Rodríguez Mañas L. [Differential characteristics of type 2 diabetes in the elderly. Role of dipeptidyl peptidase 4 inhibitors]. Rev Esp Geriatr Gerontol 2015; 51:44-51. [PMID: 26073221 DOI: 10.1016/j.regg.2015.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 04/21/2015] [Indexed: 12/30/2022]
Abstract
The prevalence of type 2 diabetes mellitus increases with age, reaching rates around 30% in those over 75 years. The type 2 diabetes mellitus in the elderly has different pathophysiological and clinical characteristics from those of the younger diabetic patient. Some differential aspects in this population are the lower life expectancy and the frequent comorbidity, frailty and associated disability. Avoiding hypoglycemia is a therapeutic priority, given their increased risk of severe hypoglycemia. It is a situation in which the benefits of intensive glycemic control are virtually non-existent, thus prevention of side effects of treatments becomes a priority. Therefore, the goals of glycemic control should be less stringent than in the general population (glycated hemoglobin>7%), and the drugs of choice should be those with a low risk of side effects (especially hypoglycemia) and well tolerated. Dipeptidyl peptidase 4 inhibitors (iDPP4) are particularly useful in this age group, either as a second drug added to metformin monotherapy, or as first line when metformin is contraindicated or not tolerated. In this article the evidence available on the efficacy and tolerance of different pharmacological options available in population over 70 years is reviewed.
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Affiliation(s)
- Francesc Formiga
- Programa de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, IDIBELL, ĹHospitalet de Llobregat, Barcelona, España.
| | - Ricardo Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, España
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Abstract
INTRODUCTION Dipeptidyl peptidase-4 (DPP-4) inhibitors (gliptins) occupy a growing place in the armamentarium of drugs used for the management of hyperglycemia in type 2 diabetes, although some safety concerns have been raised in recent years. AREAS COVERED An updated review providing an analysis of available safety data (meta-analyses, randomized controlled trials, observational cohort and case-control studies and pharmacovigilance reports) with five commercialized DPP-4 inhibitors (sitagliptin, vildagliptin, saxagliptin, alogliptin, linagliptin). A special focus is given to overall safety profile; pancreatic adverse events (AEs) (acute pancreatitis, pancreatic cancer); overall cardiovascular safety (myocardial infarction and stroke); congestive heart failure concern and finally, safety in special populations (elderly, renal impairment). EXPERT OPINION The good tolerance/safety profile of DPP-4 inhibitors has been largely confirmed, including in more fragile populations (elderly, renal impairment) with almost no increased risk of infection or gastrointestinal AEs, no weight gain and a minimal risk of hypoglycemia. Although an increased risk of acute pancreatitis and pancreatic cancer was suspected, the complete set of available data appears reassuring so far. Cardiovascular safety of DPP-4 inhibitors has been proven but an unexpected increased risk of heart failure has been reported which should be confirmed in ongoing trials and better understood. Further postmarketing surveillance is recommended.
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Affiliation(s)
- André J Scheen
- University of Liège, CHU Sart Tilman, Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine , (B35), B-4000 Liege 1 , Belgium +32 4 3667238 ; +32 4 3667068 ; andre.scheen @ chu.ulg.ac.be
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