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Abdul-Ghani M, Maffei P, DeFronzo RA. Managing insulin resistance: the forgotten pathophysiological component of type 2 diabetes. Lancet Diabetes Endocrinol 2024; 12:674-680. [PMID: 39098317 DOI: 10.1016/s2213-8587(24)00127-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/15/2024] [Accepted: 04/29/2024] [Indexed: 08/06/2024]
Abstract
Glucagon-like peptide-1 (GLP-1) receptor agonists have gained widespread use in the treatment of individuals with type 2 diabetes because of their potent weight loss promoting effect, ability to augment β-cell function, and cardiovascular protective effects. However, despite causing impressive weight loss, GLP-1 receptor agonists do not normalise insulin sensitivity in people with type 2 diabetes and obesity, and the long-term effects of this class of antidiabetic medication on muscle mass, frailty, and bone density have been poorly studied. Although GLP-1 receptor agonists improve insulin sensitivity secondary to weight loss, the only true direct insulin-sensitising drugs are thiazolidinediones. Because of side-effects associated with type 2 diabetes therapy, these drugs have not gained widespread use. In lieu of the important role of insulin resistance in the cause of type 2 diabetes and in the pathogenesis of atherosclerotic cardiovascular disease in type 2 diabetes, development of potent insulin-sensitising drugs that can be used in combination with GLP-1 receptor agonists remains a large unmet need in the management of individuals with type 2 diabetes.
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Abdul-Ghani T, Puckett C, Migahid O, Abdelgani S, Migahed A, Adams J, Triplitt C, DeFronzo R, Jayyousi A, Abdul-Ghani M. Type 2 diabetes subgroups and response to glucose-lowering therapy: Results from the EDICT and Qatar studies. Diabetes Obes Metab 2022; 24:1810-1818. [PMID: 35581905 DOI: 10.1111/dom.14767] [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] [Received: 02/28/2022] [Revised: 04/20/2022] [Accepted: 05/08/2022] [Indexed: 11/29/2022]
Abstract
AIM To examine the efficacy of glucose-lowering medications in subgroups of patients with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS Cluster analysis was performed in participants in the Efficacy and Durability of Initial Combination Therapy for Type 2 Diabetes (EDICT) study and the Qatar study using age, body mass index (BMI), glycated haemoglobin (HbA1c), and homeostatic model assessment of insulin resistance (HOMA-IR) and beta-cell function (HOMA-β). Participants also underwent an oral glucose tolerance test with measurement of plasma glucose, insulin and C-peptide concentrations to derive independent measures of insulin secretion and insulin sensitivity. The response to glucose-lowering therapies (change in HbA1c) was measured in each participant cluster for 3 years. RESULTS Three distinct and comparable clusters/groups of T2DM patients were identified in both the EDICT and Qatar studies. Participants in Group 1 had the highest HbA1c and manifested severe insulin deficiency. Participants in Group 3 had comparable insulin sensitivity to those in Group 1 but better beta-cell function and better glucose control. Participants in Group 2 had the highest BMI with severe insulin resistance accompanied by marked hyperinsulinaemia, which was primarily attributable to decreased insulin clearance. Unexpectedly, participants in Group 1 had better response to combination therapy with pioglitazone plus exenatide than with insulin therapy or metformin sequentially followed by glipizide and basal insulin, while participants in Group 2 responded equally well to both therapies despite very severe insulin resistance. CONCLUSION Distinct metabolic phenotypes characterize different T2DM clusters and differential responses to glucose-lowering therapies. Participants with severe insulin deficiency respond better to agents that preserve beta-cell function, while, surprisingly, patients with severe insulin resistance did not respond favourably to insulin sensitizers.
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Affiliation(s)
- Tamam Abdul-Ghani
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | - Curtiss Puckett
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | | | - Siham Abdelgani
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | | | - John Adams
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | - Curtis Triplitt
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | - Ralph DeFronzo
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | | | - Muhammad Abdul-Ghani
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
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Abdelgani S, Puckett C, Adams J, Triplitt C, DeFronzo RA, Abdul-Ghani M. Insulin Secretion Predicts the Response to Antidiabetic Therapy in Patients With New-onset Diabetes. J Clin Endocrinol Metab 2021; 106:3497-3504. [PMID: 34343296 PMCID: PMC8787634 DOI: 10.1210/clinem/dgab403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The results of the present study demonstrate that beta cell function in newly diagnosed T2DM patients is the key predictor of response to glucose lowering medications and provides a practical tool (C-Pep120 /C-Pep0) to guide the choice of glucose lowering agent. OBJECTIVE This work aims to identify predictors for individualization of antidiabetic therapy in patients with new-onset type 2 diabetes mellitus (T2DM). METHODS A total of 261 drug-naive participants in the Efficacy and Durability of Initial Combination Therapy for Type 2 Diabetes (EDICT) study, with new-onset diabetes, were randomly assigned in a single-center study to receive 1) metformin followed by glipizide and then insulin glargine on failure to achieve glycated hemoglobin A1c (HbA1c) less than 6.5%, or 2) initial triple therapy with metformin/pioglitazone/exenatide. Each patient received a 75-g oral glucose tolerance test (OGTT) prior to start of therapy. Factors that predicted response to therapy were identified using the area under the receiver operating characteristic curve method. RESULTS Thirty-nine patients started and maintained the treatment goal (HbA1c < 6.5%) on metformin only, and did not require intensification of antihyperglycemic therapy; 54 patients required addition of glipizide to metformin; and 47 patients required insulin addition to metformin plus glipizide for glucose control. The plasma C-peptide concentration (C-Pep)120/C-Pep0 ratio during the OGTT was the strongest predictor of response to therapy. Patients with a ratio less than 1.78 were more likely to require insulin for glucose control, whereas patients with a ratio greater than 2.65 were more likely to achieve glucose control with metformin monotherapy. In patients started on initial triple therapy, the HbA1c decreased independently of the C-Pep120/C-Pep0 ratio. CONCLUSION The increase in C-Pep above fasting following glucose load predicts the response to antihyperglycemic therapy in patients with new-onset diabetes. C-Pep120/C-Pep0 provides a useful tool for the individualization of antihyperglycemic therapy in patients with new-onset T2DM.
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Affiliation(s)
- S Abdelgani
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | - C Puckett
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | - J Adams
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | - C Triplitt
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | - R A DeFronzo
- Correspondence: Ralph A. DeFronzo, MD, Diabetes Division, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, 78229, USA.
| | - M Abdul-Ghani
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
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Abdul-Ghani M, DeFronzo RA. Personalized approach for type 2 diabetes pharmacotherapy: where are we and where do we need to be? Expert Opin Pharmacother 2021; 22:2113-2125. [PMID: 34435523 DOI: 10.1080/14656566.2021.1967319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Cluster analysis has identified distinct groups of type 2 diabetes (T2D) subjects with distinct metabolic characteristics. Thus, personalizing pharmacologic therapy to individual phenotypic and pathophysiologic characteristics has potential to improve metabolic control and reduce risk of microvascular and macrovascular complications. AREAS COVERED The authors review the classification of T2D, genetic markers, pathophysiology and natural history of T2D, the ABCDE approach to therapy, the ADA/EASD stepwise approach to therapy, available antidiabetic agents, and provide a more rational therapeutic approach based upon pathophysiology and cardiovascular and renal outcome trials. EXPERT OPINION Although insulin resistance is the earliest detectable abnormality, overt T2D does not occur in the absence of progressive beta cell failure. Because of the complex etiology of T2D (Ominous Octet), initiation of therapy with combined agents that (i) target both insulin resistance and beta cell dysfunction and (ii) prevent macrovascular, as well as microvascular, complications will be required. The ratio of C-peptide at 120 minutes (OGTT) to baseline C-peptide predicts with high sensitivity who will respond to metformin, the response to glucose-lowering agents and provides a useful tool to guide optimal glucose lowering therapy.
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Li L, Sun J, Ruan L, Song Q. Time-Series Analysis of Continuous Glucose Monitoring Data to Predict Treatment Efficacy in Patients with T2DM. J Clin Endocrinol Metab 2021; 106:2187-2197. [PMID: 34010405 DOI: 10.1210/clinem/dgab356] [Citation(s) in RCA: 2] [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: 01/26/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT There is a challenge to predict treatment effects in patients with type 2 diabetes mellitus (T2DM). OBJECTIVE To assess and predict treatment effects in patients with T2DM through time-series analysis of continuous glucose monitoring (CGM) measurements. METHOD We extracted and clustered the trend components of CGM measurements to generate representative time-series profiles, which were used as a predictor of treatment effects in groups of patients. SETTING AND PARTICIPANTS We recruited 111 outpatients with T2DM at Ningbo City First Hospital, China. INTERVENTION The patients underwent CGM measurement for 14 days at the beginning of glucose-lowering treatment. MAIN OUTCOME MEASURES Hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) were obtained at the beginning and after 6 months of treatment. RESULTS 111 patients each had 960 to 1344 CGM measurements for 14 days at 96 measurements per day. The patients were classified into 3 groups according to the profiles of trend components of CGM observed values by time-series clustering method, including decreasing (47 patients), increasing (26 patients), and unchanged (38 patients) profiles. After 6 months of glucose-lowering treatment, FPG declined from 10.2 to 6.8 mmol/L (a decline of 3.4 mmol/L) in the decreasing group, from 8.9 to 9.2 mmol/L (a rise of 0.3 mmol/L) in the increasing group, and from 8.4 to 7.5 mmol/L (a decline of 0.9 mmol/L) in the unchanged group. The changes of HbA1c were 2.3%, 0.2%, and 0.9% for the 3 groups (P < 0.01), respectively. CONCLUSIONS Clustering of the trend components of CGM data generates representative CGM profiles that are predictive of 6-month therapeutic effects for T2DM.
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Affiliation(s)
- Li Li
- Department of Endocrinology and Metabolism, Ningbo City First Hospital, Ningbo, Zhejiang Province, China
| | - Jie Sun
- Department of Endocrinology and Metabolism, Ningbo City First Hospital, Ningbo, Zhejiang Province, China
| | - Liemin Ruan
- Department of Psychosomatic Medicine, Ningbo City First Hospital, Ningbo, Zhejiang Province, China
| | - Qifa Song
- Medical Research Center, Ningbo City First Hospital, Ningbo, China
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Abdelgani S, Puckett C, Adams J, Triplitt C, DeFronzo RA, Abdul-Ghani M. Insulin secretion is a strong predictor for need of insulin therapy in patients with new-onset diabetes and HbA1c of more than 10%: A post hoc analysis of the EDICT study. Diabetes Obes Metab 2021; 23:1631-1639. [PMID: 33852204 PMCID: PMC8238899 DOI: 10.1111/dom.14383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/08/2021] [Accepted: 03/19/2021] [Indexed: 02/06/2023]
Abstract
AIM To identify predictors of response to glucose-lowering therapy in patients with new-onset diabetes and very high HbA1c (>10%). METHODS The study included EDICT participants with an initial HbA1c of more than 10% (N = 104). All subjects received a 75-g oral glucose tolerance test (OGTT) before initiation of therapy, and then were randomized to receive: (a) initial triple therapy with metformin, pioglitazone and exenatide versus (b) stepwise conventional therapy with metformin followed by glipizide and then glargine insulin to reduce HbA1c to less than 6.5%. Insulin secretion and insulin resistance were calculated with OGTT-derived indices. RESULTS Sixty-one per cent of participants in the conventional therapy group achieved HbA1c of less than 6.5% at 6 months without need of insulin therapy compared with 78% in the triple therapy group (P = NS). Insulin secretion at baseline was the strongest predictor of subjects who did not require insulin therapy; a cut point of CPEP120 /CPEP0 -the ratio between plasma C-peptide concentration at 120 minutes during the OGTT and fasting plasma C-peptide concentration-of more than 1.7 predicted subjects who achieved the treatment target without insulin, irrespective of the fasting plasma glucose (FPG) concentration and whether or not they were started on conventional or triple therapy. Subjects with a CPEP120 /CPEP0 of less than 1.7 plus FPG of 269 mg/dL or less (≤14.9 mmoL/L) also achieved the treatment goal with triple therapy. CONCLUSION Insulin secretion in response to a 75-g OGTT predicts the need for insulin therapy at the time of type 2 diabetes (T2D) diagnosis. A cut point of 1.7 of CPEP120 /CPEP0 provides a useful clinical tool to individualize glucose-lowering therapy in patients with new-onset T2D and HbA1c of more than 10%.
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Affiliation(s)
- Siham Abdelgani
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | - Curtiss Puckett
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | - John Adams
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | - Curtis Triplitt
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | - Ralph A DeFronzo
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
| | - Muhammad Abdul-Ghani
- Division of Diabetes, University of Texas Health Science Center and Texas Diabetes Institute, San Antonio, Texas, USA
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Abdul-Ghani M, Migahid O, Megahed A, DeFronzo RA, Al-Ozairi E, Jayyousi A. Combination therapy with pioglitazone/exenatide improves beta-cell function and produces superior glycaemic control compared with basal/bolus insulin in poorly controlled type 2 diabetes: A 3-year follow-up of the Qatar study. Diabetes Obes Metab 2020; 22:2287-2294. [PMID: 32729222 DOI: 10.1111/dom.14153] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/15/2020] [Accepted: 07/27/2020] [Indexed: 01/09/2023]
Abstract
AIM To examine the long-term efficacy of thiazolidinedione plus a glucagon-like peptide-1 receptor agonist versus basal-bolus insulin on glycaemic control and beta-cell function in patients with poorly controlled type 2 diabetes (T2D) on metformin plus sulphonylurea. MATERIALS AND METHODS Three hundred and thirty-one patients with poorly controlled T2D were recruited over 3 years and were followed for an additional year. Subjects received a 75 g oral glucose tolerance test (OGTT) at baseline and at study end. After completing the baseline OGTT, subjects were randomized to receive either pioglitazone plus weekly exenatide (combination therapy) or basal/bolus insulin (insulin therapy) to maintain an HbA1c of less than 7.0%. The primary outcome of the study was the difference in HbA1c at study end between the two treatment groups. RESULTS Both therapies caused a robust decrease in HbA1c. However, combination therapy caused a greater decrement (-1.1%, P < .0001) than insulin therapy, and more subjects in the combination therapy group (86%) achieved the American Diabetes Association goal of glycaemic control (HbA1c < 7.0%) than those in the insulin therapy group (44%) (P < .0001). Both therapies improved insulin secretion. However, the improvement in insulin secretion with combination therapy was 2.5-fold greater (P < .001) than with insulin therapy (50%). Insulin therapy caused more weight gain and hypoglycaemia. CONCLUSION Both combination therapy and insulin therapy effectively reduced HbA1c in poorly controlled T2D on multiple oral agents. However, combination therapy produced a greater improvement in insulin secretion and decrease in HbA1c with a lower risk of hypoglycaemia.
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Affiliation(s)
- Muhammad Abdul-Ghani
- Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
- Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Osama Migahid
- Academic Health System, Hamad General Hospital, Doha, Qatar
| | - Ayman Megahed
- Academic Health System, Hamad General Hospital, Doha, Qatar
| | - Ralph A DeFronzo
- Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | | | - Amin Jayyousi
- Academic Health System, Hamad General Hospital, Doha, Qatar
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Yaribeygi H, Atkin SL, Pirro M, Sahebkar A. A review of the anti-inflammatory properties of antidiabetic agents providing protective effects against vascular complications in diabetes. J Cell Physiol 2018; 234:8286-8294. [PMID: 30417367 DOI: 10.1002/jcp.27699] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 10/15/2018] [Indexed: 12/18/2022]
Abstract
The global prevalence of Type 2 diabetes mellitus and its associated complications are growing rapidly. Although the role of hyperglycemia is well recognized in the pathophysiology of diabetic complications, its exact underlying mechanisms are not fully understood. In this regard, accumulating evidence suggests that the role of inflammation appears pivotal, with studies showing that most diabetic complications are associated with an inflammatory response. Several classes of antidiabetic agents have been introduced for controlling glycemia, with evidence that these pharmacological agents may have modulatory effects on inflammation beyond their glucose-lowering activity. Here we review the latest evidence on the anti-inflammatory effects of commonly used antidiabetic medications and discuss the relevance of these effects on preventing diabetic complications.
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Affiliation(s)
- Habib Yaribeygi
- Chronic Kidney Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Matteo Pirro
- Department of Medicine, Unit of Internal Medicine, Angiology and Arteriosclerosis Diseases, University of Perugia, Perugia, Italy
| | - Amirhossein Sahebkar
- Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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