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Zhang C, Shi Y, Liu C, Sudesh SM, Hu Z, Li P, Liu Q, Ma Y, Shi A, Cai H. Therapeutic strategies targeting mechanisms of macrophages in diabetic heart disease. Cardiovasc Diabetol 2024; 23:169. [PMID: 38750502 PMCID: PMC11097480 DOI: 10.1186/s12933-024-02273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 05/08/2024] [Indexed: 05/18/2024] Open
Abstract
Diabetic heart disease (DHD) is a serious complication in patients with diabetes. Despite numerous studies on the pathogenic mechanisms and therapeutic targets of DHD, effective means of prevention and treatment are still lacking. The pathogenic mechanisms of DHD include cardiac inflammation, insulin resistance, myocardial fibrosis, and oxidative stress. Macrophages, the primary cells of the human innate immune system, contribute significantly to these pathological processes, playing an important role in human disease and health. Therefore, drugs targeting macrophages hold great promise for the treatment of DHD. In this review, we examine how macrophages contribute to the development of DHD and which drugs could potentially be used to target macrophages in the treatment of DHD.
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Affiliation(s)
- Chaoyue Zhang
- Cardiovascular Clinical Medical Center, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yunke Shi
- Cardiovascular Clinical Medical Center, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Changzhi Liu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shivon Mirza Sudesh
- Faculty of Medicine, St. George University of London, London, UK
- University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | - Zhao Hu
- Department of Geriatric Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Pengyang Li
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Qi Liu
- Wafic Said Molecular Cardiology Research Laboratory, The Texas Heart Institute, Houston, TX, USA
| | - Yiming Ma
- Cardiovascular Clinical Medical Center, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ao Shi
- Faculty of Medicine, St. George University of London, London, UK.
- University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus.
| | - Hongyan Cai
- Cardiovascular Clinical Medical Center, The First Affiliated Hospital of Kunming Medical University, Kunming, China.
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An J, Choi H, Choi J, Lim H, Huh W, Oh Y, Park JS, Han J, Lim S, Lim C, Kim T, Moon J, Youn H. Effect of the sodium-glucose cotransporter-2 inhibitor, DWP16001, as an add-on therapy to insulin for diabetic dogs: A pilot study. Vet Med Sci 2024; 10:e1454. [PMID: 38686463 PMCID: PMC11058604 DOI: 10.1002/vms3.1454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/21/2024] [Accepted: 04/04/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a novel class of anti-hyperglycaemic agents. OBJECTIVE This study aimed to evaluate the safety and the adjuvant glycaemic control effect of an SGLT2 inhibitor, DWP16001, in diabetic dogs receiving insulin treatment. METHODS Nineteen diabetic dogs receiving insulin treatment (NPH, porcine lente and glargine insulin) were divided into two groups according to dosing frequency: DWP TOD group (n = 10) and DWP SID group (n = 9). In the DWP TOD group, 0.025 mg/kg of DWP16001 was administered once every 3 days, whereas, in the DWP SID group, 0.025 mg/kg of DWP16001 was administered once a day. Food intake was maintained during the trial period. Hypoglycaemia, ketoacidosis or unexpected life-threatening reactions were assessed as adverse effects before and after DWP16001 administration. We compared insulin requirement reduction and blood glucose level control between two groups. RESULTS No specific adverse effects were observed during the clinical trial, and haematological parameter remained unchanged. Moreover, the fasting glucose levels and daily insulin dose in the DWP TOD group were lower than the pre-administration values, but not significantly different for 8 weeks. Systolic blood pressure, fructosamine and insulin dose decreased significantly in the DWP SID group compared to the DWP TOD group at 8 weeks (p < 0.05) without affecting food consumption. Among these patients, 10 patients were monitored while receiving DWP16001 for 12 months (DWP TOD group n = 5, DWP SID group n = 5). The fasting glucose and fructosamine levels and daily insulin dose were reduced in both groups at 12 months compared with those before receiving DWP16001. CONCLUSION When DWP16001, an SGLT2 inhibitor, was supplied to dogs with type 1 diabetes, no adverse effects were observed, and it was confirmed that the administered insulin dose can be reduced in controlling blood glucose.
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Affiliation(s)
- Ju‐Hyun An
- Department of Veterinary Emergency and Critical Care Medicine and Institute of Veterinary ScienceCollege of Veterinary MedicineKangwon National UniversityChuncheon‐siRepublic of Korea
| | - Han‐Sol Choi
- Laboratory of Veterinary Internal MedicineDepartment of Veterinary Clinical ScienceCollege of Veterinary MedicineSeoul National UniversityGwanak‐guSeoulRepublic of Korea
| | - Ji‐Soo Choi
- Daewoong PharmaceuticalLife Science InstituteYonginGyeonggi‐doRepublic of Korea
| | - Hyun‐Woo Lim
- Daewoong PharmaceuticalLife Science InstituteYonginGyeonggi‐doRepublic of Korea
| | - Wan Huh
- Daewoong PharmaceuticalLife Science InstituteYonginGyeonggi‐doRepublic of Korea
| | - Ye‐In Oh
- Department of Veterinary Internal MedicineCollege of Veterinary MedicineKyungpook National UniversityDaeguRepublic of Korea
| | - Joon Seok Park
- Daewoong PharmaceuticalLife Science InstituteYonginGyeonggi‐doRepublic of Korea
| | - Jumi Han
- Daewoong PharmaceuticalLife Science InstituteYonginGyeonggi‐doRepublic of Korea
| | - Soo Lim
- Department of Internal Medicine, Seoul National University College of MedicineSeoul National University Bundang HospitalSeongnamRepublic of Korea
| | - Chae‐Young Lim
- Nowon 24 hours N Animal Medical CenterNowon‐guSeoulRepublic of Korea
| | - Tae‐Hee Kim
- Laboratory of Veterinary Internal MedicineDepartment of Veterinary Clinical ScienceCollege of Veterinary MedicineSeoul National UniversityGwanak‐guSeoulRepublic of Korea
| | - Jae‐Bong Moon
- Daewoong petBoneunsa‐roGangnam‐guSeoulRepublic of Korea
| | - Hwa‐Young Youn
- Laboratory of Veterinary Internal MedicineDepartment of Veterinary Clinical ScienceCollege of Veterinary MedicineSeoul National UniversityGwanak‐guSeoulRepublic of Korea
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Nakamura Y, Horie I, Kitamura T, Kusunoki Y, Nishida K, Yamamoto A, Hirota Y, Fukui T, Maeda Y, Minami M, Matsui T, Kawakami A, Abiru N. Glucagon secretion and its association with glycaemic control and ketogenesis during sodium-glucose cotransporter 2 inhibition by ipragliflozin in people with type 1 diabetes: Results from the multicentre, open-label, prospective study. Diabetes Obes Metab 2024; 26:1605-1614. [PMID: 38253809 DOI: 10.1111/dom.15458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
AIM Clinical trials showed the efficacy of sodium-glucose cotransporter 2 inhibitors for type 1 diabetes (T1D) by significant reductions in body weight and glycaemic variability, but elevated susceptibility to ketoacidosis via elevated glucagon secretion was a potential concern. The Suglat-AID evaluated glucagon responses and its associations with glycaemic control and ketogenesis before and after T1D treatment with the sodium-glucose cotransporter 2 inhibitor, ipragliflozin. METHODS Adults with T1D (n = 25) took 50-mg open-labelled ipragliflozin daily as adjunctive to insulin. Laboratory/clinical data including continuous glucose monitoring were collected until 12 weeks after the ipragliflozin initiation. The participants underwent a mixed-meal tolerance test (MMTT) twice [before (first MMTT) and 12 weeks after ipragliflozin treatment (second MMTT)] to evaluate responses of glucose, C-peptide, glucagon and β-hydroxybutyrate. RESULTS The area under the curve from fasting (0 min) to 120 min (AUC0-120min) of glucagon in second MMTT were significantly increased by 14% versus first MMTT. The fasting and postprandial β-hydroxybutyrate levels were significantly elevated in second MMTT versus first MMTT. The positive correlation between postprandial glucagon secretion and glucose excursions observed in first MMTT disappeared in second MMTT, but a negative correlation between fasting glucagon and time below range (glucose, <3.9 mmol/L) appeared in second MMTT. The percentage changes in glucagon levels (fasting and AUC0-120min) from baseline to 12 weeks were significantly correlated with those in β-hydroxybutyrate levels. CONCLUSIONS Ipragliflozin treatment for T1D increased postprandial glucagon secretion, which did not exacerbate postprandial hyperglycaemia but might protect against hypoglycaemia, leading to reduced glycaemic variability. The increased glucagon secretion might accelerate ketogenesis when adequate insulin is not supplied.
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Affiliation(s)
- Yuta Nakamura
- Department of Endocrinology and Metabolism, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ichiro Horie
- Department of Endocrinology and Metabolism, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tadahiro Kitamura
- Metabolic Signal Research Center, Institute for Molecular and Cellular Regulation, Gunma University, Maebashi, Japan
| | - Yoshiki Kusunoki
- Department of Diabetes, Endocrinology and Clinical Immunology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kenro Nishida
- Division of Diabetes and Endocrinology, Kumamoto Central Hospital, Kumamoto, Japan
| | - Akane Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yushi Hirota
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoyasu Fukui
- Division of Diabetes, Metabolism, and Endocrinology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yasutaka Maeda
- Minami Diabetes Clinical Research Center, Clinic Masae Minami, Fukuoka, Japan
| | - Masae Minami
- Minami Diabetes Clinical Research Center, Clinic Masae Minami, Fukuoka, Japan
| | - Takanori Matsui
- Faculty of Bioscience and Biotechnology, Fukui Prefectural University, Fukui, Japan
| | - Atsushi Kawakami
- Department of Endocrinology and Metabolism, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Norio Abiru
- Department of Endocrinology and Metabolism, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Nan J, Wang D, Zhong R, Liu F, Luo J, Tang P, Song X, Zhang L. Sodium glucose cotransporter2 inhibitors for type 1 diabetes mellitus: A meta-analysis of randomized controlled trials. Prim Care Diabetes 2024; 18:17-24. [PMID: 37980217 DOI: 10.1016/j.pcd.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/08/2023] [Accepted: 10/22/2023] [Indexed: 11/20/2023]
Abstract
AIMS Sodium glucose cotransporter2 (SGLT2) inhibitors are controversial in the treatment of type 1 diabetes mellitus (T1DM). This study is a systematic evaluation of the safety of SGLT2 inhibitors usage in T1DM. METHODS Comprehensive literature search in six databases from inception to September 2022. Randomized controlled trials (RCTs) of T1DM treated with SGLT2 inhibitor vs. placebo were included. Data were extracted from the literature that met the inclusion criteria. After quality evaluation by the Cochrane risk bias assessment tool, meta-analysis was performed using Revman 5.4 and Stata 17.1. RESULTS The study consisted of 16 RCTs with 7192 patients. The results indicated that SGLT2inhibitors reduce glycated hemoglobin (HbA1c, Mean difference (MD)- 0.29%, P < 0.05), fasting plasma glucose (FPG, MD-0.85 mmol/L, P < 0.05), mean amplitude of glucose excursions (MAGE, 15.75 mg/dL, P < 0.05), body weight (MD-3.49 kg, P < 0.05), and total insulin dosage (MD-7.14 IU/day, P < 0.05). Furthermore, cautious SGLT2 inhibitors did not induce the risk of hypoglycemia (RR1.00, P = 0.86), urinary tract infections (RR1.02, P = 0.085), and diarrhea (RR1.34, P = 0.523). CONCLUSION Based on this meta-analysis, SGLT22 inhibitors reduce insulin dosage without increasing the risk of hypoglycemia and diabetic ketoacidosis for type 1 diabetes mellitus in 1month.
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Affiliation(s)
- Juanli Nan
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Dekai Wang
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Ruxian Zhong
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Fen Liu
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Jingmei Luo
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Ping Tang
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China
| | - Xiaoxiao Song
- School of Public Health, Kunming Medical University, Kunming 650500, China
| | - Lihua Zhang
- Department of General Practice, The First Affiliated Hospital of Kunming Medical University, Kunming 650031, China.
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Li M, Liu Z, Yang X, Zhang J, Han M, Zhang Y, Liu Y. The effect of sodium-glucose cotransporter 2 inhibitors as an adjunct to insulin in patients with type 1 diabetes assessed by continuous glucose monitoring: A systematic review and meta-analysis. J Diabetes Complications 2023; 37:108632. [PMID: 37907042 DOI: 10.1016/j.jdiacomp.2023.108632] [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: 06/16/2023] [Revised: 10/07/2023] [Accepted: 10/19/2023] [Indexed: 11/02/2023]
Abstract
AIMS Patients undergoing insulin-based therapy for type 1 diabetes often experience poor glycemic control characterized by significant fluctuations. This study was undertaken to analyze the effect of sodium-glucose cotransporter 2 inhibitors (SGLT2Is), as an adjunct to insulin, on time in range (TIR) and glycemic variability in patients with type 1 diabetes, using continuous glucose monitoring (CGM). In addition, we examined which type of SGLT2I yielded a superior effect compared to others. METHODS We conducted a comprehensive search of PubMed, EMBASE, the Cochrane Library, Web of Science, and clinical trial registry websites, retrieving all eligible randomized clinical trials (RCTs) published up until February 2023. We analyzed the mean TIR, mean amplitude of glucose excursions (MAGE), mean daily glucose (MDG), diabetic ketoacidosis (DKA), standard deviation (SD), total insulin dose, and severe hypoglycemia to evaluate the efficacy and safety of SGLT2Is. A random-effects model was also employed. RESULTS This study encompassed 15 RCTs. The meta-analysis revealed that the use of SGLT2Is as an adjuvant therapy to insulin led to a significant increase in TIR (MD = 10.78, 95%CI = 9.33-12.23, I2 = 42 %, P < 0.00001) and a decrease in SD (MD = -0.38, 95%CI = -0.50 to -0.26, I2 = 0 %, P < 0.00001), MAGE (MD = -0.92, 95%CI = -1.17 to -0.67, I2 = 19 %, P < 0.00001), MDG(MD = -1.01, 95%CI = -1.32 to -0.70, I2 = 48 %, P < 0.00001), and total insulin dose (MD = -5.81, 95%CI = -7.81 to -3.82, I2 = 32 %, P < 0.00001). No significant increase was observed in the rate of severe hypoglycemia (RR = 1.04, 95 % CI = 0.76-1.43, P = 0.80). However, SGLT2I therapy was associated with increased DKA occurrence (RR = 2.79, 95 % CI = 1.42-5.48; P = 0.003, I2 = 16 %). In addition, the subgroup analyses based on the type of SGLT2Is revealed that dapagliflozin might exhibit greater efficacy compared to other SGLT2Is across most outcomes. CONCLUSIONS SGLT2Is exhibited a positive effect on improving blood glucose level fluctuations. Subgroup analysis showed that dapagliflozin appeared to have more advantages. However, giving due consideration to preventing adverse effects, particularly DKA, is paramount. REGISTRATION Prospero CRD42023408276.
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Affiliation(s)
- Mengnan Li
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, China; First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Zi'ang Liu
- The Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Xifeng Yang
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, China; First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Jiaxin Zhang
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, China; First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Minmin Han
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, China; First Clinical Medical College, Shanxi Medical University, Taiyuan, China
| | - Yi Zhang
- Department of Pharmacology, Shanxi Medical University, Taiyuan, China.
| | - Yunfeng Liu
- Department of Endocrinology, First Hospital of Shanxi Medical University, Taiyuan, China.
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Marx N, Federici M, Schütt K, Müller-Wieland D, Ajjan RA, Antunes MJ, Christodorescu RM, Crawford C, Di Angelantonio E, Eliasson B, Espinola-Klein C, Fauchier L, Halle M, Herrington WG, Kautzky-Willer A, Lambrinou E, Lesiak M, Lettino M, McGuire DK, Mullens W, Rocca B, Sattar N. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J 2023; 44:4043-4140. [PMID: 37622663 DOI: 10.1093/eurheartj/ehad192] [Citation(s) in RCA: 148] [Impact Index Per Article: 148.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Saha S, Saha S, Gayen M. Treatment-duration-wise harm profile of insulin-sodium-glucose co-transporter inhibitor co-treatment in type 1 diabetes mellitus patients. J Diabetes Metab Disord 2023; 22:673-701. [PMID: 37255836 PMCID: PMC10225433 DOI: 10.1007/s40200-023-01192-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/26/2023] [Indexed: 06/01/2023]
Abstract
Background The treatment duration of insulin-sodium-glucose co-transporter inhibitors (SGLTis) co-treatment of type 1 diabetes mellitus (T1DM) patients in randomized controlled trials (RCTs) varies by 1-52 weeks. Henceforth, treatment duration-wise, we compared the following insulin-treatment adjuncts- mega- versus low-dose SGLTis, SGLTis versus placebo, and different SGLTi dosages. Method Double-blinded RCTs reporting the above were searched (using terms like insulin-dependent, "juvenile-onset diabetes," and "sodium glucose cotransport*") in the PubMed, Embase, and Scopus databases and appraised using a Cochrane tool. The risks across different SGLTi-dosages were compared using network meta-analysis. Random-effect pairwise meta-analysis was performed for the remaining harm juxtapositions. Meta-analyses were performed for the following treatment durations- < 4 weeks, 4 to < 24 weeks, and ≥ 24 weeks. For meta-analysis and certainty of evidence assessment, we used the Stata statistical software and the GRADE method, respectively. Results A total of 15 (low risks of bias) studies sourcing data from about 7,330 T1DM patients were reviewed. Meta-analysis findings of ≥ 24 weeks long trials were- a. SGLTi-insulin co-treatment increased the genital infection (GI) (RR: 3.51; 95% CI: 2.59, 4.77), diabetic ketoacidosis (DKA) and (RR: 3.25; 95% CI:1.29, 8.16), and serious side effects (RR: 1.43; 95% CI: 1.05, 1.94) risk. b. SGLT2i-insulin increased the GI risk (RR: 3.77; 95% CI: 2.31, 6.16; high-quality evidence). c. Sotagliflozin-insulin increased the GI (RR: 3.36; 95% CI: 2.28, 4.96) and DKA (RR: 6.69; 95% CI: 2.75, 16.32) risk (both high-quality evidence). Compared to low-dose, megadose SGLTi treatment for 4 to < 24 weeks increased the GI risk. The remaining analyses were not statistically significantly different. Conclusion On moderate to long-term treatment (24-52 weeks) of T1DM patients, insulin-SGLT2i co-treatment was associated with GI risk, and insulin-sotagliflozin co-treatment was associated with DKA and GI risk. Supplementary Information The online version contains supplementary material available at 10.1007/s40200-023-01192-7.
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Affiliation(s)
- Sumanta Saha
- Department of Community Medicine, R. G. Kar Medical College, Kolkata, West Bengal India
| | - Sujata Saha
- Department of Mathematics, Mankar College, Mankar, West Bengal India
| | - Mohan Gayen
- Department of Community Medicine, R. G. Kar Medical College, Kolkata, West Bengal India
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Khadem H, Nemat H, Elliott J, Benaissa M. Blood Glucose Level Time Series Forecasting: Nested Deep Ensemble Learning Lag Fusion. Bioengineering (Basel) 2023; 10:bioengineering10040487. [PMID: 37106674 PMCID: PMC10135844 DOI: 10.3390/bioengineering10040487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
Blood glucose level prediction is a critical aspect of diabetes management. It enables individuals to make informed decisions about their insulin dosing, diet, and physical activity. This, in turn, improves their quality of life and reduces the risk of chronic and acute complications. One conundrum in developing time-series forecasting models for blood glucose level prediction is to determine an appropriate length for look-back windows. On the one hand, studying short histories foists the risk of information incompletion. On the other hand, analysing long histories might induce information redundancy due to the data shift phenomenon. Additionally, optimal lag lengths are inconsistent across individuals because of the domain shift occurrence. Therefore, in bespoke analysis, either optimal lag values should be found for each individual separately or a globally suboptimal lag value should be used for all. The former approach degenerates the analysis's congruency and imposes extra perplexity. With the latter, the fine-tunned lag is not necessarily the optimum option for all individuals. To cope with this challenge, this work suggests an interconnected lag fusion framework based on nested meta-learning analysis that improves the accuracy and precision of predictions for personalised blood glucose level forecasting. The proposed framework is leveraged to generate blood glucose prediction models for patients with type 1 diabetes by scrutinising two well-established publicly available Ohio type 1 diabetes datasets. The models developed undergo vigorous evaluation and statistical analysis from mathematical and clinical perspectives. The results achieved underpin the efficacy of the proposed method in blood glucose level time-series prediction analysis.
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Affiliation(s)
- Heydar Khadem
- Department of Electronic and Electrical Engineering, University of Sheffield, Sheffield S10 2TN, UK
| | - Hoda Nemat
- Department of Electronic and Electrical Engineering, University of Sheffield, Sheffield S10 2TN, UK
| | - Jackie Elliott
- Department of Oncology and Metabolism, University of Sheffield, Sheffield S10 2TN, UK
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield S5 7AU, UK
| | - Mohammed Benaissa
- Department of Electronic and Electrical Engineering, University of Sheffield, Sheffield S10 2TN, UK
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Blonde L, Umpierrez GE, Reddy SS, McGill JB, Berga SL, Bush M, Chandrasekaran S, DeFronzo RA, Einhorn D, Galindo RJ, Gardner TW, Garg R, Garvey WT, Hirsch IB, Hurley DL, Izuora K, Kosiborod M, Olson D, Patel SB, Pop-Busui R, Sadhu AR, Samson SL, Stec C, Tamborlane WV, Tuttle KR, Twining C, Vella A, Vellanki P, Weber SL. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract 2022; 28:923-1049. [PMID: 35963508 PMCID: PMC10200071 DOI: 10.1016/j.eprac.2022.08.002] [Citation(s) in RCA: 144] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers. METHODS The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development. RESULTS This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes. CONCLUSIONS This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.
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Affiliation(s)
| | | | - S Sethu Reddy
- Central Michigan University, Mount Pleasant, Michigan
| | | | | | | | | | | | - Daniel Einhorn
- Scripps Whittier Diabetes Institute, La Jolla, California
| | | | | | - Rajesh Garg
- Lundquist Institute/Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | | | - Darin Olson
- Colorado Mountain Medical, LLC, Avon, Colorado
| | | | | | - Archana R Sadhu
- Houston Methodist; Weill Cornell Medicine; Texas A&M College of Medicine; Houston, Texas
| | | | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | | | - Katherine R Tuttle
- University of Washington and Providence Health Care, Seattle and Spokane, Washington
| | | | | | | | - Sandra L Weber
- University of South Carolina School of Medicine-Greenville, Prisma Health System, Greenville, South Carolina
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Hotait ZS, Lo Cascio JN, Choos END, Shepard BD. The sugar daddy: the role of the renal proximal tubule in glucose homeostasis. Am J Physiol Cell Physiol 2022; 323:C791-C803. [PMID: 35912988 PMCID: PMC9448277 DOI: 10.1152/ajpcell.00225.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 11/22/2022]
Abstract
Renal blood flow represents >20% of total cardiac output and with this comes the great responsibility of maintaining homeostasis through the intricate regulation of solute handling. Through the processes of filtration, reabsorption, and secretion, the kidneys ensure that solutes and other small molecules are either returned to circulation, catabolized within renal epithelial cells, or excreted through the process of urination. Although this occurs throughout the renal nephron, one segment is tasked with the bulk of solute reabsorption-the proximal tubule. Among others, the renal proximal tubule is entirely responsible for the reabsorption of glucose, a critical source of energy that fuels the body. In addition, it is the only other site of gluconeogenesis outside of the liver. When these processes go awry, pathophysiological conditions such as diabetes and acidosis result. In this review, we highlight the recent advances made in understanding these processes that occur within the renal proximal tubule. We focus on the physiological mechanisms at play regarding glucose reabsorption and glucose metabolism, emphasize the conditions that occur under diseased states, and explore the emerging class of therapeutics that are responsible for restoring homeostasis.
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Affiliation(s)
- Zahraa S Hotait
- Department of Human Science, Georgetown University, Washington, District of Columbia
| | - Julia N Lo Cascio
- Department of Human Science, Georgetown University, Washington, District of Columbia
| | - Elijah N D Choos
- Department of Human Science, Georgetown University, Washington, District of Columbia
| | - Blythe D Shepard
- Department of Human Science, Georgetown University, Washington, District of Columbia
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11
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Liu H, Sridhar VS, Perkins BA, Rosenstock J, Cherney DZI. SGLT2 Inhibition in Type 1 Diabetes with Diabetic Kidney Disease: Potential Cardiorenal Benefits Can Outweigh Preventable Risk of Diabetic Ketoacidosis. Curr Diab Rep 2022; 22:317-332. [PMID: 35633439 DOI: 10.1007/s11892-022-01471-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to summarize existing research investigating the use of sodium glucose cotransporter-2 (SGLT2) inhibitors in patients with type 1 diabetes mellitus (T1DM) while highlighting potential strategies to mitigate the risk of diabetic ketoacidosis (DKA). RECENT FINDINGS SGLT2 inhibitors have been studied in patients with T1DM in phase 3 clinical trials such as the inTandem, DEPICT, and EASE trials, which demonstrated consistent reductions in HbA1c. Secondary analyses of these trials have also reported potential kidney protective effects that are independent of improved glycemic control. However, trials in patients with type 2 diabetes mellitus (T2DM) have found an increased risk of DKA with SGLT2 inhibitors, a serious concern in patients with T1DM. SGLT2 inhibitors provide cardiovascular benefits and kidney protection in patients with T2DM and are a promising therapeutic option for patients with T1DM due to overlapping pathophysiological mechanisms. However, SGLT2 inhibitors increase the risk of DKA, and there is currently a lack of research investigating the beneficial effects of SGLT2 inhibitors in patients with T1DM. Preventative measure for DKA would have to be implemented and the risks would need to be carefully balanced with the benefits offered by SGLT2 inhibitors. Additional research will also be required to determine the kidney protective effects of SGLT2 inhibitors in patients with T1DM and diabetic kidney disease and to quantify the risk of DKA after the implementation of preventative measures, proper patient education, and ketone monitoring.
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Affiliation(s)
- Hongyan Liu
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Vikas S Sridhar
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, Dallas, TX, USA
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Toronto General Hospital, 585 University Ave, Toronto, ON, 8N-845M5G 2N2, Canada.
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12
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Yakou F, Saburi M, Hirose A, Akaoka H, Hirota Y, Kobayashi T, Awane N, Asahi N, Amagawa T, Ozawa S, Ohno A, Matsushita T. A Case Series of Ketoacidosis After Coronavirus Disease 2019 Vaccination in Patients With Type 1 Diabetes. Front Endocrinol (Lausanne) 2022; 13:840580. [PMID: 35370952 PMCID: PMC8971718 DOI: 10.3389/fendo.2022.840580] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/10/2022] [Indexed: 12/26/2022] Open
Abstract
Introduction We report a case series of severe ketoacidosis after COVID-19 vaccination in a type 1 diabetes patients treated with insulin and an SGLT-2 inhibitor. Case Report We present two cases of type 1 diabetes mellitus. One patient was treated with insulin therapy and an SGLT-2 inhibitor, and the other patient was treated with insulin therapy alone. Both patients became ill after coronavirus disease-2019 vaccination, making it difficult to continue their diet or insulin injections. On admission, they developed severe diabetic ketoacidosis. This is the first report of ketoacidosis after coronavirus disease-2019 vaccination. Conclusion The vaccine should be carefully administered to type 1 diabetes patients receiving intensive insulin therapy and a sodium-glucose transporter due to the high risk ketoacidosis. It is important to instruct patients to drink sufficient fluids and to continue insulin injections when they become sick.
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Affiliation(s)
- Fumiyoshi Yakou
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Masuo Saburi
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Ai Hirose
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Hiroaki Akaoka
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Yusuke Hirota
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Takaaki Kobayashi
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Naoko Awane
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Nobuteru Asahi
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Toshihiro Amagawa
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | | | - Atsushi Ohno
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Takaya Matsushita
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
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13
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Abstract
The goal of diabetes treatment is to maintain good glycemic control, prevent the development and progression of diabetic complications, and ensure the same quality of life and life expectancy as healthy people. Hemoglobin A1c (HbA1c) is used as an index of glycemic control, but strict glycemic control using HbA1c as an index may lead to severe hypoglycemia and cardiovascular death. Glycemic variability (GV), such as excessive hyperglycemia and hypoglycemia, is associated with diabetic vascular complications and has been recognized as an important index of glycemic control. Here, we reviewed the definition and evaluated the clinical usefulness of GV, and its relationship with diabetic complications and therapeutic strategies to reduce GV.
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Affiliation(s)
- Yoshiki Kusunoki
- Department of Diabetes, Endocrinology and Clinical Immunology, Hyogo College of Medicine, Japan
| | - Kosuke Konishi
- Department of Diabetes, Endocrinology and Clinical Immunology, Hyogo College of Medicine, Japan
| | - Taku Tsunoda
- Department of Diabetes, Endocrinology and Clinical Immunology, Hyogo College of Medicine, Japan
| | - Hidenori Koyama
- Department of Diabetes, Endocrinology and Clinical Immunology, Hyogo College of Medicine, Japan
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14
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Li Y, Li H, Dong L, Lin D, Xu L, Lou P, Zang D, Wang K, Ma L. A Network Meta-Analysis of the Dose-Response Effects of Dapagliflozin on Efficacy and Safety in Adults With Type 1 Diabetes. Front Endocrinol (Lausanne) 2022; 13:923376. [PMID: 35872994 PMCID: PMC9301373 DOI: 10.3389/fendo.2022.923376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Most patients with type 1 diabetes (T1DM) do not reach the blood glucose goal with treatment of insulin. In our research, we intended to estimate the therapeutic effect and safety of additional different doses of dapagliflozin on insulin treatment in T1DM. METHODS We performed direct and indirect network meta-analysis using Bayesian models and graded different dosages of dapagliflozin by mixed therapy contrasts. We retrieved information from the PubMed, Embase, The Cochrane Library, Web of Science, China Biology Medicine (CBM) disc, China National Knowledge Infrastructure (CNKI), Wanfang Data, and WEIPU Data. Our research included randomized controlled trials (RCTs) including T1DM treated with insulin and additional dapagliflozin 5 mg or dapagliflozin 10 mg from January 2012 to June 2021. Thirteen RCTs with 10,701 participants were divided into three groups as below: insulin alone, dapagliflozin 5 mg + insulin, and dapagliflozin 10 mg + insulin. RESULTS Dapagliflozin dose-dependently exhibited reductions in glycated hemoglobin (HbA1c), total insulin daily dose (TDD), and body weight. Neither dapagliflozin 5 mg nor 10 mg could induce hypoglycemia or severe hypoglycemia. However, both doses of dapagliflozin increased the incidence of diabetic ketoacidosis (DKA) and genital infection. CONCLUSIONS Dapagliflozin 10 mg could achieve a better outcome in efficacy and could not increase the risk of hypoglycemia. Although it may induce a higher risk of DKA and genital infection, there was no significant difference between dapagliflozin 10 mg and 5 mg. Our outcomes indicate that dapagliflozin 10mg has a high reliability of being graded prior as a supplementary treatment to insulin in T1DM.
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Affiliation(s)
- Yinhui Li
- Department of Endocrine, Traditional Chinese Medicine Hospital Affiliated to Xinjiang Medical University, Urumqi, China
| | - Hui Li
- Department of Endocrine, Traditional Chinese Medicine Hospital Affiliated to Xinjiang Medical University, Urumqi, China
| | - Liming Dong
- Department of Clinical Nutrition, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Dandan Lin
- College of Medical Engineering and Technology, Xinjiang Medical University, Urumqi, China
| | - Lijuan Xu
- Department of Endocrine, Traditional Chinese Medicine Hospital Affiliated to Xinjiang Medical University, Urumqi, China
| | - Pengwei Lou
- Department of Medical Administration, Traditional Chinese Medicine Hospital Affiliated to Xinjiang Medical University, Urumqi, China
| | - Deng Zang
- Department of Endocrine, Traditional Chinese Medicine Hospital Affiliated to Xinjiang Medical University, Urumqi, China
| | - Kai Wang
- College of Medical Engineering and Technology, Xinjiang Medical University, Urumqi, China
- *Correspondence: Li Ma, ; Kai Wang,
| | - Li Ma
- Department of Endocrine, Traditional Chinese Medicine Hospital Affiliated to Xinjiang Medical University, Urumqi, China
- *Correspondence: Li Ma, ; Kai Wang,
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15
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Shimoda M, Mashiko A, Katakura Y, Sanada J, Fushimi Y, Obata A, Kimura T, Kohara K, Tatsumi F, Nakanishi S, Mune T, Kaku K, Kaneto H. Efficacy and safety of adding ipragliflozin to insulin in Japanese patients with type 1 diabetes mellitus: a retrospective study. Endocr J 2021; 68:1455-1461. [PMID: 34334532 DOI: 10.1507/endocrj.ej21-0161] [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] [Indexed: 11/23/2022] Open
Abstract
Advances in insulin preparations and administration methods have produced a gradual improvement in glycemic control in patients with type 1 diabetes mellitus (DM). Nevertheless, glycated hemoglobin (HbA1c) levels in patients with type 1 DM are still poor compared to those in patients with type 2 DM. Here, we sought to assess the efficacy and safety of the sodium-glucose cotransporter 2 (SGLT2) inhibitor ipragliflozin (IPRA) in patients with type 1 DM. This study was retrospectively conducted with data from type 1 DM patients who had a history of IPRA therapy. The primary endpoint was HbA1c level at 24 weeks. The baseline characteristics of a total of 12 subjects were as follows: age, 50.1 ± 13.2 years; diabetes duration, 17.3 ± 10.5 years; body mass index (BMI), 22.9 ± 2.1 kg/m2; HbA1c, 8.8 ± 1.3%; and daily insulin dose, 0.60 ± 0.21 units/kg. IPRA decreased HbA1c levels to 8.2 ± 1.2% (p < 0.05) and reduced insulin dose to 0.52 ± 0.17 units/kg (p < 0.01) after 24 weeks. HbA1c value was particularly reduced in subjects with preserved C-peptide index. IPRA significantly reduced body weight by -1.4 ± 1.4 kg (p < 0.01) 16 weeks after starting treatment, with no further weight loss after 24 weeks. There were no instances of diabetic ketoacidosis or severe hypoglycemia. IPRA exerted beneficial effects on glycemic control without any severe adverse effects, and should be safe and effective when used in patients with type 1 DM with understanding of correspondence in sick day.
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Affiliation(s)
- Masashi Shimoda
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Akiko Mashiko
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Yukino Katakura
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Junpei Sanada
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Yoshiro Fushimi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Atsushi Obata
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Tomohiko Kimura
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Kenji Kohara
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Fuminori Tatsumi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Shuhei Nakanishi
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Tomoatsu Mune
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Kohei Kaku
- Kawasaki Medical School, Kurashiki 701-0192, Japan
| | - Hideaki Kaneto
- Division of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki 701-0192, Japan
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16
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Shamchuk A, Doulla M, Jetha M. Association possible entre l’acidocétose diabétique et l’utilisation d’un inhibiteur du sodium-glucose co-transporteur 2 chez un jeune de 17 ans atteint de diabète de type 2. CMAJ 2021; 193:E1746-E1749. [PMID: 34782384 PMCID: PMC8594549 DOI: 10.1503/cmaj.202627-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Angela Shamchuk
- Département de pédiatrie, Université de l'Alberta, Edmonton, Alb
| | - Manpreet Doulla
- Département de pédiatrie, Université de l'Alberta, Edmonton, Alb
| | - Mary Jetha
- Département de pédiatrie, Université de l'Alberta, Edmonton, Alb.
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17
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Pasqua MR, Tsoukas MA, Haidar A. Strategically Playing with Fire: SGLT Inhibitors as Possible Adjunct to Closed-Loop Insulin Therapy. J Diabetes Sci Technol 2021; 15:1232-1242. [PMID: 34558336 PMCID: PMC8655283 DOI: 10.1177/19322968211035411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
As closed-loop insulin therapies emerge into clinical practice and evolve in medical research for type 1 diabetes (T1D) treatment, the limitations in these therapies become more evident. These gaps include unachieved target levels of glycated hemoglobin in some patients, postprandial hyperglycemia, the ongoing need for carbohydrate counting, and the lack of non-glycemic benefits (such as prevention of metabolic syndrome and complications). Multiple adjunct therapies have been examined to improve closed-loop systems, yet none have become a staple. Sodium-glucose-linked cotransporter inhibitors (SGLTi's) have been extensively researched in T1D, with average reductions in placebo-adjusted HbA1c by 0.39%, and total daily dose by approximately 10%. Unfortunately, many trials revealed an increased risk of diabetic ketoacidosis, as high as 5 times the relative risk compared to placebo. This narrative review discusses the proven benefits and risks of SGLTi in patients with T1D with routine therapy, what has been studied thus far in closed-loop therapy in combination with SGLTi, the potential benefits of SGLTi use to closed-loop systems, and what is required going forward to improve the benefit to risk ratio in these insulin systems.
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Affiliation(s)
- Melissa-Rosina Pasqua
- Division of Endocrinology, McGill
University Health Centre, Montreal, QC, Canada
- Melissa-Rosina Pasqua, MD, Mailing address:
McGill University Health Centre, 1001 boulevard de Décarie, Montreal, QC H4A
3J1, Canada.
| | - Michael A. Tsoukas
- Division of Endocrinology, McGill
University Health Centre, Montreal, QC, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering,
McGill University, Montreal, QC, Canada
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18
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Ando Y, Shigiyama F, Hirose T, Kumashiro N. Simplification of complex insulin regimens using canagliflozin or liraglutide in patients with well-controlled type 2 diabetes: A 24-week randomized controlled trial. J Diabetes Investig 2021; 12:1816-1826. [PMID: 33650779 PMCID: PMC8504902 DOI: 10.1111/jdi.13533] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/15/2021] [Accepted: 02/23/2021] [Indexed: 12/12/2022] Open
Abstract
AIMS/INTRODUCTION We investigated the potential use of canagliflozin, in comparison with liraglutide, as an alternative to bolus insulin in patients with well-controlled type 2 diabetes mellitus receiving multiple daily insulin injection therapy. MATERIALS AND METHODS In 40 patients, with glycated hemoglobin (HbA1c) levels <7.5% controlled by multiple daily insulin injection therapy, all bolus insulin was randomly switched to canagliflozin (100 mg/day) or liraglutide (0.3-0.9 mg/day) for 24 weeks. Basal insulin was continued with dose adjustment according to a predefined algorithm. The end-points were the change in the HbA1c level, glycemic variability assessed by continuous glucose monitoring, body mass index, insulin dose, quality of life (QOL) and safety assessments. Factors influencing the changes in QOL were also assessed using a simple regression analysis. RESULTS The change in HbA1c from baseline was comparable between the treatments. Both treatments maintained the HbA1c level to the baseline levels with stable glucose variability and no severe hypoglycemia for 24 weeks, decreased total insulin dose, and significantly increased the QOL score. The change in QOL was significantly associated with injection frequency. CONCLUSIONS For patients with well-controlled type 2 diabetes mellitus, under the support of basal insulin, complex insulin regimens can be simplified by replacing all bolus insulin with once-daily canagliflozin or liraglutide, which improves patients' QOL.
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Affiliation(s)
- Yasuyo Ando
- Division of Diabetes, Metabolism, and EndocrinologyDepartment of MedicineToho University Graduate School of MedicineTokyoJapan
| | - Fumika Shigiyama
- Division of Diabetes, Metabolism, and EndocrinologyDepartment of MedicineToho University Graduate School of MedicineTokyoJapan
| | - Takahisa Hirose
- Division of Diabetes, Metabolism, and EndocrinologyDepartment of MedicineToho University Graduate School of MedicineTokyoJapan
| | - Naoki Kumashiro
- Division of Diabetes, Metabolism, and EndocrinologyDepartment of MedicineToho University Graduate School of MedicineTokyoJapan
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19
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Glycemic Variability Impacted by SGLT2 Inhibitors and GLP 1 Agonists in Patients with Diabetes Mellitus: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10184078. [PMID: 34575189 PMCID: PMC8470178 DOI: 10.3390/jcm10184078] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/25/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022] Open
Abstract
To investigate the effect of sodium-glucose cotransporter 2 (SGLT-2) inhibitors and glucagon-like peptide 1 (GLP-1) agonists on glycemic variability (GV), the mean amplitude of glucose excursion (MAGE), mean blood glucose (MBG) levels, and percentage of time maintaining euglycemia were evaluated. Randomized controlled trials evaluating the efficacy of SGLT-2 inhibitors and GLP-1 agonists for treating people with diabetes were selected through searches of PubMed, EMBASE, and other databases. Sixteen studies were finally analyzed. There were no differences in the reductions in MAGE after treatment with SGLT-2 inhibitors or GLP-1 agonists (standardized mean difference (SMD) = −0.59, 95% CI = −0.82 to −0.36 vs. SMD = −0.43, 95% CI = −0.51 to −0.35, respectively), and treatment with SGLT-2 inhibitors was associated with an increased reduction in MBG levels (SMD = −0.56, 95% CI = −0.65 to −0.48, p < 0.00001). Monotherapy and add-on therapy with medications were correlated with MAGE and MBG level reductions. In conclusion, SGLT-2 inhibitors and GLP-1 agonists were associated with a reduction in GV and could be alternatives for treating people with diabetes.
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20
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Shamchuk A, Doulla M, Jetha M. Possible association between diabetic ketoacidosis and use of sodium-glucose co-transporter 2 inhibitor in a 17-year-old youth with type 2 diabetes. CMAJ 2021; 193:E1385-E1388. [PMID: 34493565 PMCID: PMC8443299 DOI: 10.1503/cmaj.202627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Angela Shamchuk
- Department of Pediatrics, University of Alberta, Edmonton, Alta
| | - Manpreet Doulla
- Department of Pediatrics, University of Alberta, Edmonton, Alta
| | - Mary Jetha
- Department of Pediatrics, University of Alberta, Edmonton, Alta.
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21
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Abstract
PURPOSE OF REVIEW Type 1 diabetes mellitus (T1DM) is associated with increased mortality, with premature cardiovascular disease (CVD) a major factor. To date, research has identified multiple risk factors for this excess CVD liability. However, gaps remain in our understanding of the underlying mechanisms. RECENT FINDINGS T1DM is generally diagnosed at a young age. Since cardiovascular complications often only manifest at a later stage of life, there is generally less focus in earlier years on reducing CVD risk for affected individuals. This is an area that requires improvement as risk factors might be managed from earlier age to reduce later development of CVD. In this review, we discuss the evidence for cardiovascular risk factors, risk prediction models, candidate surrogate measurements and CVD risk management.
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Affiliation(s)
- I H Teoh
- Diabetes, Endocrinology & Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - P Elisaus
- Diabetes, Endocrinology & Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - J D Schofield
- Diabetes, Endocrinology & Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
- Division of Diabetes, Endocrinology & Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
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22
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Brown E, Heerspink HJL, Cuthbertson DJ, Wilding JPH. SGLT2 inhibitors and GLP-1 receptor agonists: established and emerging indications. Lancet 2021; 398:262-276. [PMID: 34216571 DOI: 10.1016/s0140-6736(21)00536-5] [Citation(s) in RCA: 209] [Impact Index Per Article: 69.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/12/2021] [Accepted: 02/24/2021] [Indexed: 12/21/2022]
Abstract
SGLT2 inhibitors and GLP-1 receptor agonists are used in patients with type 2 diabetes as glucose lowering therapies, with additional benefits of weight loss and blood pressure reduction. Data from cardiovascular outcome trials have highlighted that these drugs confer protection against major cardiovascular disease in those with established atherosclerotic cardiovascular disease, reduce the risk of admission to hospital for heart failure, and reduce cardiovascular and all-cause mortality. Ongoing research using hard renal endpoints such as end stage kidney disease rather than surrogate markers might clarify the renoprotective benefits of both agents. When used for glucose lowering, SGLT2 inhibitors are most effective if the estimated glomerular filtration rate is more than 60 ml per min per 1·73m2 at initiation and should be avoided where there is a risk of diabetic ketoacidosis. GLP-1 receptor agonists are contraindicated in those with a history of medullary thyroid cancer and used with caution in patients with a history of pancreatitis of a known cause. These drugs are now second-line, or even arguably first-line, glucose lowering therapies in patients with cardiorenal disease, irrespective of glycaemic control. If an SGLT2 inhibitor or GLP-1 receptor agonist is considered suitable in patients with type 2 diabetes, treatment should be prioritised according to existing evidence: GLP-1 receptor agonists should be considered in patients at a high risk of, or with established, cardiovascular disease and SGLT2 inhibitors considered for patients with heart failure (with reduced ejection fraction) or chronic kidney disease (with or without established cardiovascular disease). There is now compelling data on the benefits of these drugs for a range of other clinical indications even without type 2 diabetes, including for GLP-1 receptor agonists in patients with obesity and overweight with weight-related comorbidities.
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Affiliation(s)
- Emily Brown
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Liverpool University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, UK
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Daniel J Cuthbertson
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Liverpool University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, UK.
| | - John P H Wilding
- Department of Metabolic and Cardiovascular Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Liverpool University Hospitals NHS Foundation Trust, Longmoor Lane, Liverpool, UK
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Rao L, Ren C, Luo S, Huang C, Li X. Sodium-glucose cotransporter 2 inhibitors as an add-on therapy to insulin for type 1 diabetes mellitus: Meta-analysis of randomized controlled trials. Acta Diabetol 2021; 58:869-880. [PMID: 33651228 PMCID: PMC8187227 DOI: 10.1007/s00592-021-01686-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
AIMS The aim was to systematically review the efficacy and safety of sodium-glucose cotransporter inhibitor (SGLT2i) as an adjunct to insulin at different follow-up durations in randomized, double-blind clinical trials in patients with type 1 diabetes. METHODS We conducted a search on Medline, Embase, and the Cochrane Library for relevant studies published before May 2020. According to the duration of follow-up, the subgroup analysis included four periods: 1-4, 12-18, 24-26, and 52 weeks. In the five trials included both 24-26 and 52 weeks of follow-up, we compared the efficacy by the placebo-subtracted difference and changes in SGLT2i groups. RESULTS Fifteen trials including 7109 participants were analyzed. The combination of SGLT2i and insulin improved hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), daily insulin dose, body weight, and blood pressure, which varied greatly by different follow-ups. Compared with %HbA1c at 24-26 weeks, placebo-subtracted differences and changes in the SGLT2i groups slightly increased. SGLT2i plus insulin treatment showed no difference in the occurrence of urinary tract infections (UTIs), hypoglycemia, or severe hypoglycemia but increased the risk of genital tract infections (GTIs) in a duration-dependent manner. SGLT2i treatment was associated with a significantly higher rate of ketone-related SAEs and diabetic ketoacidosis (DKA) at 52 weeks. CONCLUSION SGLT2i as an add-on therapy to insulin improved glycemic control and body weight and decreased the required dose of insulin without increasing the risk of hypoglycemia. However, after 6 months the benefits of SGLT2is on glycemic control may weaken and the risks of GTIs and DKA increased.
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Affiliation(s)
- Lunwen Rao
- Huangdu Community Health Service Center, Jiading District, Anting TownShanghai, China
| | - Chenhong Ren
- Postgraduate Training Basement of Jinzhou Medical University, Taihe Hospital, Hubei University of Medical, Shiyan, China
- Department of Endocrinology, Taihe Hospital, Hubei University of Medical, Shiyan, 442000, China
| | - Shan Luo
- Department of Endocrinology, Taihe Hospital, Hubei University of Medical, Shiyan, 442000, China
| | - Chenghu Huang
- Department of Endocrinology, The People's Hospital of Bishan District, Bishan, Chongqing, 402760, China.
| | - Xuefeng Li
- Department of Endocrinology, Taihe Hospital, Hubei University of Medical, Shiyan, 442000, China.
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Mukai J, Kanno S, Kubota R. A literature review and meta-analysis of safety profiles of SGLT2 inhibitors in Japanese patients with diabetes mellitus. Sci Rep 2021; 11:13472. [PMID: 34188120 PMCID: PMC8241876 DOI: 10.1038/s41598-021-92925-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/17/2021] [Indexed: 01/10/2023] Open
Abstract
The safety profiles of sodium-glucose co-transporter 2 (SGLT2) inhibitors may depend on races/ethnicities. We aimed to assess the safety profiles of SGLT2 inhibitors in Japanese patients with diabetes mellitus (DM). The electronic databases MEDLINE, CENTRAL, and Ichushi-web were searched for studies with no language restriction from their inception to August 2019. Trials were included in the analysis if they were randomized controlled trials (RCTs) comparing the effects of SGLT2 inhibitors with a placebo in Japanese patients with DM > 18 years and reporting HbA1c and at least 1 adverse event. We calculated risk ratios with 95% CIs and used a random-effects model. Of the 22 RCTs included in our review, only 1 included patients with type 1 DM. The durations of RCTs ranged between 4 and 24 weeks. In comparison with a placebo, SGLT2 inhibitors were associated with similar risks of hypoglycemia, urinary tract infection, genital infection, hypovolemia, and fracture. The outcomes of treatment with SGLT2 inhibitors among Japanese patients with DM suggest favorable safety profiles. However, further evidence from studies with a longer duration, involving more diverse populations, such as patients with different types of DM, or including individual SGLT2 inhibitors is needed to resolve the limitations of the present study.
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Affiliation(s)
- Junichi Mukai
- Division of Clinical Pharmacy (Laboratory of Clinical Pharmacy Education) and Research and Education Center for Clinical Pharmacy, School of Pharmacy, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8641, Japan.
| | - Shinya Kanno
- Division of Clinical Pharmacy (Laboratory of Clinical Pharmacy Education) and Research and Education Center for Clinical Pharmacy, School of Pharmacy, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8641, Japan
| | - Rie Kubota
- Division of Clinical Pharmacy (Laboratory of Clinical Pharmacy Education) and Research and Education Center for Clinical Pharmacy, School of Pharmacy, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8641, Japan
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Baba Y, Ishibashi R, Takasaki A, Ito C, Watanabe A, Tokita M, Meguro M, Harama T, Hirayama K, Yamamoto T, Nakamura S, Koshizaka M, Maezawa Y, Uchida D, Okajima F. Effects of Sodium Glucose Co-Transporter 2 Inhibitors in Type 1 Diabetes Mellitus on Body Composition and Glucose Variabilities: Single-Arm, Exploratory Trial. Diabetes Ther 2021; 12:1415-1427. [PMID: 33738773 PMCID: PMC8099976 DOI: 10.1007/s13300-021-01047-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/02/2021] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Sodium glucose co-transporter 2 (SGLT2) inhibitors are widely used in the management of type 2 diabetes mellitus; they prevent cardiovascular events and reduce fat mass. However, little is known about the effects of SGLT2 inhibitors on type 1 diabetes mellitus as an adjuvant to insulin therapy. Therefore, we aimed to elucidate the effects of SGLT2 inhibitors on body composition of patients with type 1 diabetes mellitus and assess blood glucose variability. METHODS A single-center, single-arm, prospective, interventional study was performed on Japanese patients with type 1 diabetes mellitus who were not administered SGLT2 inhibitors prior to this study. These patients were equipped with flash glucose monitoring (FGM) and administered ipragliflozin 50 mg daily. Body composition was evaluated using bioelectrical impedance analysis, and glycemic variabilities were assessed using FGM before and after SGLT2 inhibitor treatment. RESULTS After 52 weeks of treatment, the total fat mass tended to be reduced (- 9.10% from baseline, P = 0.098). In addition, skeletal muscle mass also decreased (- 2.98% from baseline, P = 0.023). Although the basal insulin dose was reduced, SGLT2 inhibitors decreased HbA1c levels. FGM revealed that glycemic variabilities were also reduced, and time within the target glucose range increased (51.7% vs. 62.5%, P = 0.004). CONCLUSION SGLT2 inhibitors have beneficial effects on glycemic variabilities and fat mass reductions in patients with type 1 diabetes mellitus. However, loss of skeletal muscle is a major concern; therefore, caution is required when using SGLT2 inhibitors in lean patients with type 1 diabetes mellitus. TRIAL REGISTRATION University Hospital Medical Information Network Clinical Trial Registry (UMIN000042407).
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Affiliation(s)
- Yusuke Baba
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Chiba, Japan
| | - Ryoichi Ishibashi
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Chiba, Japan.
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Atsushi Takasaki
- Department of Diabetes, Endocrinology and Metabolism, Japanese Red Cross Narita Hospital, Chiba, Japan
| | - Chiho Ito
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Chiba, Japan
| | - Atsuko Watanabe
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Chiba, Japan
| | - Megumi Tokita
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Chiba, Japan
| | - Miwako Meguro
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Chiba, Japan
| | - Tomomi Harama
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Chiba, Japan
| | - Kiichi Hirayama
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Chiba, Japan
| | - Tetsuya Yamamoto
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Chiba, Japan
| | - Susumu Nakamura
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Chiba, Japan
| | - Masaya Koshizaka
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Chiba, Japan
| | - Yoshiro Maezawa
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
- Division of Diabetes, Metabolism and Endocrinology, Chiba University Hospital, Chiba, Japan
| | - Daigaku Uchida
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Kimitsu Chuo Hospital, Chiba, Japan
| | - Fumitaka Okajima
- Department of Diabetes, Endocrinology and Metabolism, Nippon Medical School, Chiba Hokusoh Hospital, Chiba, Japan
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Kordonouri O, Kerner W. [Type 1 diabetes: an update]. Internist (Berl) 2021; 62:627-637. [PMID: 33825933 PMCID: PMC8024935 DOI: 10.1007/s00108-021-01009-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 12/02/2022]
Abstract
Die Inzidenz des Diabetes mellitus Typ 1 (T1D) steigt seit 30 Jahren stetig an, insbesondere bei Kindern und Jugendlichen, sodass es alle 20 Jahre zu einer Verdoppelung der Fallzahlen in dieser Altersgruppe kommt. Die verspätete Diagnose oder falsche Interpretation der Symptome führt zur lebensgefährlichen diabetischen Ketoazidose, an der jedes dritte Kind in Deutschland bei Manifestation des T1D leidet. In der Insulintherapie des T1D bei Kindern, Jugendlichen und Erwachsenen gibt es keine prinzipiellen Unterschiede. Die Anwendung einer Insulinpumpentherapie und kontinuierlichen Glukosemessung nimmt stetig zu. Hiermit sollen hypo- und hyperglykämische Episoden reduziert, die Zeit im Zielbereich erhöht und das Hämoglobin‑A1c-Therapieziel unter 7 % erreicht werden. Neben der Vermeidung diabetesbedingter mikrovaskulärer Langzeitkomplikationen ist die rechtzeitige Erkennung und Behandlung kardiovaskulärer Risikofaktoren auch bei jungen Menschen mit T1D von außerordentlicher Bedeutung.
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Affiliation(s)
- Olga Kordonouri
- Allgemeinpädiatrie, Diabetologie, Endokrinologie, Gastroenterologie und Klinische Forschung, Kinder- und Jugendkrankenhaus AUF DER BULT, Janusz-Korczak-Allee 12, 30173, Hannover, Deutschland.
| | - Wolfgang Kerner
- Klinik für Diabetes und Stoffwechselerkrankungen, Klinikum Karlsburg, Karlsburg, Deutschland
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Cardiovascular benefits of sodium-glucose cotransporter 2 inhibitors in diabetic and nondiabetic patients. Cardiovasc Diabetol 2021; 20:78. [PMID: 33827579 PMCID: PMC8028072 DOI: 10.1186/s12933-021-01266-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/19/2021] [Indexed: 12/25/2022] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) were developed as antidiabetic agents, but accumulating evidence has shown their beneficial effects on the cardiovascular system. Analyses of the EMPA-REG OUTCOME trial (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients) suggested that these benefits are independent of glycemic control. Several large-scale outcome trials of SGLT2i also showed cardiovascular benefits in nondiabetic patients, strengthening this perspective. Extensive animal and clinical studies have likewise shown that mechanisms other than the antihyperglycemic effect underlie the cardiovascular benefits. Recent clinical guidelines recommend the use of SGLT2i in patients with type 2 diabetes mellitus and cardiovascular diseases because of the proven cardiovascular protective effects. Since the cardiovascular benefits are independent of glycemic control, the therapeutic spectrum of SGLT2i will likely be extended to nondiabetic patients.
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Zou H, Liu L, Guo J, Wang H, Liu S, Xing Y, Deng C, Xiao Y, Zhou Z. Sodium-glucose cotransporter inhibitors as add-on therapy in addition to insulin for type 1 diabetes mellitus: A meta-analysis of randomized controlled trials. J Diabetes Investig 2021; 12:546-556. [PMID: 33245620 PMCID: PMC8015835 DOI: 10.1111/jdi.13387] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/06/2020] [Accepted: 08/09/2020] [Indexed: 12/16/2022] Open
Abstract
AIMS/INTRODUCTION Several clinical trials reported the effects of sodium-glucose cotransporter (SGLT) inhibitors in type 1 diabetes patients. This meta-analysis aimed to assess the efficacy and safety of SGLT inhibitors in type 1 diabetes patients. MATERIALS AND METHODS Relevant studies were identified in the PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure and Wan Fang databases through 1 April 2020. Differences were expressed as the 95% confidence interval (CI) or weighted mean difference (WMD) for continuous outcomes, and risk ratio (RR) for discontinuous outcomes. RESULTS A total of 13 RCTs with 7,962 cases were included. SGLT inhibitors reduced the fasting plasma glucose level (WMD -1.320 mmol/L, 95% CI -1.609 to -1.031, P < 0.001), glycated hemoglobin level (WMD -0.386%, 95% CI -0.431 to -0.342, P < 0.001) and daily total insulin dose (WMD -5.403, 95% CI -7.218 to -3.859, P < 0.001). However, higher risks of diabetic ketoacidosis (RR 5.042, 95% CI 3.160-8.046, P < 0.001), urinary tract infections (RR 1.259, 95% CI 1.034-1.533,P = 0.022) and genital infections (RR 2.995, 95% CI 1.953-4.594, P < 0.001) were associated with SGLT inhibitors, but SGLT inhibitors did not increase the hypoglycemia risk (RR 0.980, 95% CI 0.840-1.144,P = 0.799). In subgroup analysis, with a significant reduction of fasting plasma glucose, glycated hemoglobin and daily insulin doses, SGLT1/2 inhibitor did not increase genitourinary tract infections compared with a placebo. CONCLUSIONS SGLT2 and SGLT1/2 inhibitors can improve glycemic control in patients with type 1 diabetes.
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Affiliation(s)
- Hailan Zou
- Department of Metabolism and EndocrinologyThe Second Xiangya HospitalCentral South UniversityChangshaHunanChina
- National Clinical Research Center for Metabolic DiseasesChangshaHunanChina
| | - Lili Liu
- Department of Metabolism and EndocrinologyThe Second Xiangya HospitalCentral South UniversityChangshaHunanChina
- National Clinical Research Center for Metabolic DiseasesChangshaHunanChina
| | - Jia Guo
- Xiangya School of NursingCentral South UniversityChangshaChina
| | - Hongjuan Wang
- Xiangya School of NursingCentral South UniversityChangshaChina
| | - Siyun Liu
- Chongqing General HospitalUniversity of Chinese Academy of SciencesBeijingChina
| | - Yixuan Xing
- Department of Metabolism and EndocrinologyThe Second Xiangya HospitalCentral South UniversityChangshaHunanChina
- National Clinical Research Center for Metabolic DiseasesChangshaHunanChina
| | - Chao Deng
- Department of Metabolism and EndocrinologyThe Second Xiangya HospitalCentral South UniversityChangshaHunanChina
- National Clinical Research Center for Metabolic DiseasesChangshaHunanChina
| | - Yang Xiao
- Department of Metabolism and EndocrinologyThe Second Xiangya HospitalCentral South UniversityChangshaHunanChina
- National Clinical Research Center for Metabolic DiseasesChangshaHunanChina
| | - Zhiguang Zhou
- Department of Metabolism and EndocrinologyThe Second Xiangya HospitalCentral South UniversityChangshaHunanChina
- National Clinical Research Center for Metabolic DiseasesChangshaHunanChina
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Kurozumi A, Okada Y, Tanaka Y. Glucose-lowering effects of 7-day treatment with SGLT2 inhibitor confirmed by intermittently scanned continuous glucose monitoring in outpatients with type 1 diabetes. A pilot study. Endocr J 2021; 68:361-369. [PMID: 33208570 DOI: 10.1507/endocrj.ej20-0577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The present study used intermittently scanned continuous glucose monitoring (isCGM) in 10 patients with type 1 diabetes mellitus (T1DM) to evaluate the efficacy and safety of 7-day outpatient treatment with the combination of intensive insulin therapy and sodium-glucose transporter 2 inhibitor (SGLT2-I). All participants wore isCGM and were treated with either 50 mg/day ipragliflozin or 5 mg/day dapagliflozin. The primary outcome, percent time with glucose at 70-180 mg/dL (TIR: time in range), improved significantly following the addition of SGLT2-I (p = 0.005). TIR increased from 36.0% before addition of SGLT2-I to 70.7% on day 7. Although none of the patients achieved TIR of 70% or higher before the addition of SGLT2-I, 6 patients met that criteria TIR on day 7. The secondary outcome measures, standard deviation (SD) of glucose, average plasma glucose, percent time with glucose at >180 mg/dL (TAR: time above range), maximum plasma glucose, high blood glucose index (HBGI) and average nocturnal plasma glucose (midnight to 05:59 AM) detected by isCGM, also improved significantly by SGLT2-I. There were no significant differences in percent time with glucose at <70 mg/dL (TBR: time below range), minimum plasma glucose and low blood glucose index (LBGI). Our results using isCGM in an actual clinical setting showed that 7-day use of SGLT2-I with intensive insulin therapy improved plasma glucose fluctuations and mean plasma glucose levels without inducing hypoglycemia in patients with T1DM.
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Affiliation(s)
- Akira Kurozumi
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan
| | - Yosuke Okada
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan
| | - Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu 807-8555, Japan
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Huang Y, Jiang Z, Wei Y. Efficacy and safety of the SGLT2 inhibitor dapagliflozin in type 1 diabetes: A meta-analysis of randomized controlled trials. Exp Ther Med 2021; 21:382. [PMID: 33680104 PMCID: PMC7918543 DOI: 10.3892/etm.2021.9813] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/05/2020] [Indexed: 12/16/2022] Open
Abstract
Sodium glucose cotransporter-2 (SGLT2) is a sodium-dependent glucose transporter responsible for renal absorption of glucose. Dapagliflozin is an SGLT2 inhibitor used in patients with type 1 diabetes to promote urinary glucose excretion, but to date, randomized controlled trials (RCTs) to evaluate the effect of this drug in this disease have not been systematically evaluated. Therefore, the aim of the present study was to evaluate the efficacy and safety of dapagliflozin, as an adjuvant therapy to insulin, in the treatment of type 1 diabetes mellitus through a systematic review and meta-analysis. The Cochrane Library Database, Medline and Embase databases were used to search articles published between January 1st 2004 and February 5th 2020 with no language restrictions relating to RCTs. After extracting the data, the quality of the RCTs was evaluated and the data were statistically analyzed. A total of 4 RCTs with 1,691 participants were included. Dapagliflozin resulted in decreased glycosylated hemoglobin A1c (0.40-0.45%), body weight (2.52-3.85 kg), mean daily glucose (0.76-0.99 mmol/l) and mean amplitude of glucose excursion (0.54-1.07 mmol/l; all with P<0.00001) compared to placebo. Subgroup analysis by dose indicated no significant difference in all efficacy outcome indicators between dapagliflozin at 5 and at 10 mg (P>0.1). Compared with placebo, the use of dapagliflozin in patients with type 1 diabetes increased the risk of adverse events and serious adverse events (P<0.05), but did not increase the risks of infection, diabetic ketoacidosis (DKA) and discontinuation due to adverse events. Analysis by dose group suggested that no significant difference in all safety outcome indicators between dapagliflozin at 5 and at 10 mg (P>0.1). In conclusion, dapagliflozin had a significant effect on type 1 diabetes. However, the use of dapagliflozin significantly increased the incidence of adverse events and serious adverse events compared with placebo. Dapagliflozin-assisted short-term (24 weeks) insulin therapy for type 1 diabetes did not increase the risk of DKA but additional high-quality studies are required to determine its long-term efficacy and safety.
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Affiliation(s)
- Yuxin Huang
- Department of Clinical Medicine, The First Clinical Medical College, Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Zeju Jiang
- Department of Clinical Medicine, The First Clinical Medical College, Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Yiping Wei
- Department of Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
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Renoprotective effects of sodium-glucose cotransporter-2 inhibitors and underlying mechanisms. Curr Opin Nephrol Hypertens 2021; 29:112-118. [PMID: 31725011 DOI: 10.1097/mnh.0000000000000561] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW Emerging data have demonstrated that sodium-glucose cotransporter-2 (SGLT2) inhibitors prevent cardiovascular events, especially heart failure-associated endpoints. Cardiovascular outcome trials have also suggested their renoprotective effects. One large clinical trial investigated renal primary endpoints and demonstrated that SGLT2 inhibitors slowed the progression of diabetic kidney disease (DKD). This review summarizes clinical trial data on renal outcomes and discusses potential underlying mechanisms. RECENT FINDINGS The EMPA-REG, CANVAS, and DECLARE-TIMI 58 studies revealed that SGLT2 inhibitors reduce the risk of cardiovascular events and concomitantly suggested that these drugs slow the progression of kidney disease in type 2 diabetes. The CREDENCE trial on patients with high-risk type 2 diabetes and chronic kidney disease demonstrated that canagliflozin treatment reduced the relative risk of a composite outcome, including end-stage kidney disease, serum creatinine doubling, and renal/cardiovascular death, by 30% in these patients. Animal experiments revealed that oxidative stress, inflammation, fibrosis, and tubuloglomerular feedback are underlying renoprotective mechanisms behind SGLT2 inhibitors. SUMMARY Recent clinical trials have established the renoprotective effects of SGLT2 inhibitors. Further investigations on mechanisms of these renoprotective effects will provide deeper insights and understanding of pathogenetic properties of DKD.
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Tandon S, Ayis S, Hopkins D, Harding S, Stadler M. The impact of pharmacological and lifestyle interventions on body weight in people with type 1 diabetes: A systematic review and meta-analysis. Diabetes Obes Metab 2021; 23:350-362. [PMID: 33026152 DOI: 10.1111/dom.14221] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/09/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022]
Abstract
AIM To systematically review the effects of pharmacological and lifestyle interventions on body weight as a secondary outcome in people with type 1 diabetes. METHODS The Ovid Medline, Embase and Cochrane Library databases were searched for relevant pharmacological (glucagon-like peptide-1 [GLP-1] receptor agonist, sodium-glucose co-transporter-2 [SGLT-2] inhibitor, dipeptidyl peptidase-4 [DPP-4] inhibitor and metformin) and lifestyle intervention studies (diet and exercise) for adults with type 1 diabetes reporting body weight change and HbA1c published from January 2000 to May 2020. Meta-analyses were performed for 16 randomized controlled trials (RCTs). RESULTS Thirty-three RCTs (n = 9344 participants), 26 pharmacological (on average 43.9 years, 83.1 kg, HbA1c 8.1%; 55.8% male) and seven lifestyle-based interventions (on average 37.0 years, 85.0 kg, HbA1c 8.1%; 84.6% male), were analysed. The GLP-1 receptor agonist liraglutide 0.6 mg (mean difference [MD]: -2.22 kg [95% CI: -2.55 to -1.90]), 1.2 mg (MD: -3.74 kg [95% CI: -4.16 to -3.33]) and 1.8 mg (MD: -4.85 kg [95% CI: -5.29 to -4.41]), and the SGLT-2 inhibitors empagliflozin 2.5 mg (MD: -1.47 kg [95% CI: -2.23 to -0.71]), 10 mg (MD: -2.77 kg [95% CI: -3.24 to -2.31]) and 25 mg (MD: -3.06 kg [95% CI: -3.57 to -2.55]) and sotagliflozin 200 mg (MD: -2.40 kg [95% CI: -2.87 to -1.94]) and 400 mg (MD: -3.23 [95% CI: -3.73 to -2.72]) were associated with significant reductions in body weight. No significant effect on body weight was found for DPP-4 inhibitors, other GLP-1-receptor agonists, metformin, or for lifestyle interventions (i.e. exercise and diet). CONCLUSIONS In people with type 1 diabetes, several adjuvant pharmacological interventions showed weight reduction as a secondary outcome. Future studies in overweight people with type 1 diabetes are needed to establish whether the lifestyle and pharmacological interventions reviewed here have potential as components of complex interventions aimed at body weight reduction as a primary outcome.
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Affiliation(s)
- Saniya Tandon
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Salma Ayis
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David Hopkins
- Institute of Diabetes Endocrinology and Obesity, King's Health Partners, London, UK
| | - Seeromanie Harding
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Marietta Stadler
- Diabetes Research Group, Weston Education Centre, King's College London, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Wang W, Zhang L, Pei X, Pan Q, Guo L. Evaluation of the safety of sodium-glucose co-transporter-2 inhibitors for treating patients with type 1 diabetes. Diabetes Obes Metab 2020; 22:1767-1776. [PMID: 32436630 DOI: 10.1111/dom.14092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/12/2020] [Accepted: 05/16/2020] [Indexed: 12/14/2022]
Abstract
AIM To conduct an overall safety assessment of sodium-glucose co-transporter-2 (SGLT-2) inhibitors used for the treatment of patients with type 1 diabetes (T1D), including ketoacidosis, genital infection, volume depletion, liver and kidney injury events, cardiovascular events, diarrhea and severe hypoglycaemia. MATERIALS AND METHODS We searched three databases (Pubmed, Embase and the Cochrane Library) for randomized controlled trials that treated T1D by using SGLT-2 inhibitors from 2000 to 5 March 2020. RESULTS Of the 1653 articles identified that fit our search criteria, 22 studies included qualitative-based results, eight of which were randomized clinical trials that included quantitative-based results. Compared with the control group, the SGLT-2 inhibitors treatment group was found to have had an increased incidence of ketoacidosis (P < .00001, OR 4.34, 95% CI [2.37, 7.96], I2 = 18%), events leading to discontinuation (P < .0001, OR 1.76, 95% CI [1.34, 2.31], I2 = 0%), genital infection (P < .00001, OR 3.64, 95% CI [2.82, 4.70], I2 = 0%), volume depletion (P = .006, OR 2.10, 95% CI [1.23, 3.59], I2 = 4%) and diarrhoea (P = .008, OR 1.64, 95% CI [1.14, 2.36], I2 = 0%). However, according to subgroup analysis, the risk of diarrhoea was dose-related. The incidence of urinary tract infection, cardiovascular events, renal events, liver injury and fracture was not significantly different for the treatment group compared with the control group. CONCLUSIONS Despite showing some promise as a treatment approach, the application of SGLT-2 inhibitors for patients with T1D should be considered with caution.
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Affiliation(s)
- Weihao Wang
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Lina Zhang
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaobei Pei
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Qi Pan
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Lixin Guo
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
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The comparison of efficacy and safety between different doses of empagliflozin in insulin-treated type 1 diabetes mellitus patients: a systematic review and meta-analysis protocol. J Diabetes Metab Disord 2020; 19:545-550. [PMID: 32550206 DOI: 10.1007/s40200-020-00544-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
Objectives The proposed review aims to compare the efficacy and safety profile of empagliflozin 25 mg with its lower dosages and placebo, respectively, in insulin-treated type 1 diabetes mellitus (T1DM) patients. Methods Double-blinded randomized controlled trials comparing the above outcomes will be searched primarily in three electronic databases (PubMed, Embase, and Scopus) and eligible trials will be included in the proposed review. Then, from the trials recruited in the review, data of the study design, participants, interventions compared, and outcomes of interest will be extracted. Subsequently, the trials' risk of bias will be assessed using the Cochrane Collaboration's tool. The meta-analysis will be conducted with a fixed-effect or a random-effect model to estimate the mean differences (weighted or standardized) and risk ratios for the efficacy and safety-related comparable outcome data, respectively. Statistical heterogeneity will be assessed by the p-value of chi-squared statistics and I2 statistics and explained by subgroup analysis and meta-regression. Publication bias will be assessed by funnel plots and Egger's test. The sensitivity analysis will repeat the meta-analysis for respective outcomes using assumptions alternative to that used in the preliminary meta-analysis and by dropping each study at a time. Results A narrative reporting will ensue if a meta-analytic comparison is not possible. Conclusions Based on the contemporary literature, the proposed review will synthesize the evidence on how the efficacy and safety profile of high dose empagliflozin varies with its lower doses and placebo, respectively, in insulin-treated T1DM patients.
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Kaku K, Isaka H, Sakatani T, Toyoshima J. Long-term (52-week) efficacy and safety of ipragliflozin add-on therapy to insulin in Japanese patients with type 1 diabetes mellitus: An uncontrolled, open-label extension of a phase III study. J Diabetes Investig 2020; 11:662-671. [PMID: 31743569 PMCID: PMC7232286 DOI: 10.1111/jdi.13181] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 11/06/2019] [Accepted: 11/17/2019] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The aim of the present study was to assess the long-term (52-week) efficacy and safety of ipragliflozin in insulin-treated Japanese patients with type 1 diabetes mellitus and inadequate glycemic control. MATERIALS AND METHODS In this 28-week, open-label extension of a multicenter, randomized, placebo-controlled, 24-week phase III study, ipragliflozin recipients continued treatment (50 mg, once daily), and placebo recipients were switched to once-daily 50 mg ipragliflozin at the start of the extension period. The ipragliflozin dose could be increased to 100 mg if warranted. The primary end-point was change in glycated hemoglobin; secondary end-points were change in insulin dose and bodyweight. Safety outcomes were monitored as treatment-emergent adverse events. RESULTS A total of 53 (placebo switched to ipragliflozin) and 108 (ipragliflozin) patients completed the open-label extension (treatment period 2), with 24 and 44 patients, respectively, receiving dose increases. From baseline to end of treatment, the overall mean change (standard deviation [SD]) in glycated hemoglobin was -0.33% (0.72; -3.7 mmol/mol [7.9]), with changes in basal, bolus and total insulin doses of -3.76 IU (SD 3.85 IU), -2.51 IU (SD 7.08 IU) and -6.27 IU (SD 8.16 IU), respectively. No serious drug-related treatment-emergent adverse events or deaths were reported. Treatment-emergent adverse events leading to study discontinuation occurred in zero and three (2.6%) patients in the placebo switched to ipragliflozin and ipragliflozin groups, respectively; all were considered drug-related. There were no cases of severe hypoglycemia or diabetic ketoacidosis, and no safety concerns related to dose increase. CONCLUSIONS The efficacy and safety of 50 mg, once-daily ipragliflozin in insulin-treated type 1 diabetes mellitus patients were confirmed in this long-term, open-label extension study. No safety concerns were attributed to a dose increase to 100 mg.
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Affiliation(s)
- Kohei Kaku
- Department of MedicineKawasaki Medical SchoolOkayamaJapan
| | - Hiroyuki Isaka
- Japan/Asia Clinical DevelopmentAstellas Pharma Inc.TokyoJapan
| | | | - Junko Toyoshima
- Clinical Pharmacology and Exploratory DevelopmentAstellas Pharma Inc.TokyoJapan
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Bayona Cebada A, Nattero-Chávez L, Alonso Díaz S, Escobar-Morreale HF, Luque-Ramírez M. Efficacy and Safety of SGLT2 Inhibitors in Type 1 Diabetes After the Introduction of an Off-Label Use Protocol for Clinical Practice. Diabetes Technol Ther 2020; 22:208-215. [PMID: 31644310 DOI: 10.1089/dia.2019.0316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Aims: We evaluated the real-life efficacy and safety of empagliflozin in combination with optimized insulin therapy in patients with type 1 diabetes (T1D). Methods: This was a prospective study, including 27 patients with T1D treated with insulin therapy to whom empagliflozin was added according to an off-label protocol approved for use in clinical practice. The primary end point was the change in HbA1c 52 weeks after the addition of empagliflozin to insulin therapy. Blood pressure (BP), weight, and safety were also assessed. Results: At week 52, the addition of empagliflozin significantly reduced HbA1c from 8.0% ± 0.7% to 7.2% ± 0.8% (P < 0.001). The mean percentage of time in range for capillary glucose monitoring increased from 50% to 62% (P = 0.008) in parallel to a -0.08 IU/(kg·day) reduction in insulin requirements (P = 0.031). There was also a reduction in the body weight (-8 kg) and in systolic BP from 134 to 127 mmHg (P < 0.001). The most commonly reported adverse events were genitourinary infections (10 episodes in 52 weeks of follow-up). One patient developed an episode of mild diabetic ketoacidosis that motivated empagliflozin withdrawal. No severe hypoglycemic events were registered. Conclusions: Our results suggested that the use of empagliflozin following a strict off-label protocol may represent an effective and safe option in real life among patients with T1D, improving metabolic control, and ameliorating some cardiovascular risk factors.
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Affiliation(s)
- Ane Bayona Cebada
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Lía Nattero-Chávez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBER Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Sara Alonso Díaz
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Héctor F Escobar-Morreale
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBER Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
- Department of Medicine, University of Alcalá, Madrid, Spain
| | - Manuel Luque-Ramírez
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Diabetes, Obesity and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBER Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
- Department of Medicine, University of Alcalá, Madrid, Spain
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Yamada T, Iwasaki K, Maedera S, Ito K, Takeshima T, Noma H, Shojima N. Myocardial infarction in type 2 diabetes using sodium-glucose co-transporter-2 inhibitors, dipeptidyl peptidase-4 inhibitors or glucagon-like peptide-1 receptor agonists: proportional hazards analysis by deep neural network based machine learning. Curr Med Res Opin 2020; 36:403-409. [PMID: 31855074 DOI: 10.1080/03007995.2019.1706043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Aims: Some hypoglycemic therapies are associated with lower risk of cardiovascular outcomes. We investigated the incidence of cardiovascular disease among patients with type 2 diabetes using antidiabetic drugs from three classes, which were sodium-glucose co-transporter-2 inhibitors (SGLT-2is), glucagon-like peptide-1 receptor agonists (GLP-1RAs) and dipeptidyl peptidase-4 inhibitors (DPP-4is).Materials and methods: We compared the risk of myocardial infarction (MI) among these drugs and developed a machine learning model for predicting MI in patients without prior heart disease. We analyzed US health plan data for patients without prior MI or insulin therapy who were aged ≥40 years at initial prescription and had not received oral antidiabetic drugs for ≥6 months previously. After developing a machine learning model to predict MI, proportional hazards analysis of MI incidence was conducted using the risk obtained with this model and the drug classes as explanatory variables.Results: We analyzed 199,116 patients (mean age: years), comprising 110,278 (58.6) prescribed DPP-4is, 43,538 (55.1) prescribed GLP-1RAs and 45,300 (55.3) prescribed SGLT-2is. Receiver operating characteristics analysis showed higher precision of machine learning over logistic regression analysis. Proportional hazards analysis by machine learning revealed a significantly lower risk of MI with SGLT-2is or GLP-1RAs than DPP-4is (hazard ratio: 0.81, 95% confidence interval: 0.72-0.91, p = .0004 vs. 0.63, 0.56-0.72, p < .0001). MI risk was also significantly lower with GLP-1RAs than SGLT-2is (0.77, 0.66-0.90, p = .001).Limitations: All patients analyzed were covered by US commercial health plans, so information on patients aged ≥65 years was limited and the socioeconomic background may have been biased. Also, the observation period differed among the three classes of drugs due to differing release dates.Conclusions: Machine learning analysis suggested the risk of MI was 37% lower for type 2 diabetes patients without prior MI using GLP-1RAs versus DPP-4is, while the risk was 19% lower for SGLT-2is versus DPP-4is.
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Affiliation(s)
- Tomohide Yamada
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kosuke Iwasaki
- Japan Healthcare Practice and Data Analytics, Milliman Inc., Tokyo, Japan
| | - Shotaro Maedera
- Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Katsuya Ito
- Department of Economics, University of Tokyo, Tokyo, Japan
| | - Tomomi Takeshima
- Japan Healthcare Practice and Data Analytics, Milliman Inc., Tokyo, Japan
| | - Hisashi Noma
- Department of Data Science, The Institute of Statistical Mathematics, Tokyo, Japan
| | - Nobuhiro Shojima
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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Zelniker TA, Braunwald E. Clinical Benefit of Cardiorenal Effects of Sodium-Glucose Cotransporter 2 Inhibitors: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 75:435-447. [PMID: 32000956 DOI: 10.1016/j.jacc.2019.11.036] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/15/2019] [Accepted: 11/17/2019] [Indexed: 12/19/2022]
Abstract
Changes in the regulatory guidelines by the U.S. Food and Drug Administration and the European Medical Agency requiring large-scale trials that study the cardiovascular safety of new glucose-lowering drugs have improved our understanding of type 2 diabetes mellitus. Unexpectedly, these trials demonstrated that sodium-glucose cotransporter 2 inhibitors reduce adverse cardiovascular outcomes. This second part of this 2-part review summarizes the findings of recent clinical trials and their clinical implications and describes ongoing trials and future areas of research.
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Affiliation(s)
- Thomas A Zelniker
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, Massachusetts. https://twitter.com/ZelnikerThomas
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, Massachusetts.
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Dimitrios P, Michael D, Vasilios K, Konstantinos S, Konstantinos I, Ioanna Z, Konstantinos P, Spyridon B, Asterios K. Liraglutide as Adjunct to Insulin Treatment in Patients with Type 1 Diabetes: A Systematic Review and Meta-analysis. Curr Diabetes Rev 2020; 16:313-326. [PMID: 31203802 DOI: 10.2174/1573399815666190614141918] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/24/2019] [Accepted: 05/03/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND A few Randomized Controlled Trials (RCTs) have evaluated the use of liraglutide in Type 1 Diabetes (T1D). Through the present systematic review and meta-analysis, we aim at critically appraising and summarizing those RCTs, providing precise effect estimates. METHODS We searched major databases and grey literature from their inception to October 2018, for RCTs with a duration ≥ 12 weeks, comparing liraglutide with placebo or any other comparator as adjunct to insulin in patients with T1D, investigating major efficacy and safety endpoints. This review is reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. RESULTS We included 5 trials with 2,445 randomized participants. Liraglutide provided modest reductions in HbA1c, with liraglutide 1.8 mg producing the greatest decrease (MD = -0.24%, 95% CI -0.32 to -0.16, I2=0%). Significant weight reduction, up to 4.87 kg with liraglutide 1.8 mg was also observed (95% CI -5.31 to -4.43, I2=0%). Decrease in total daily insulin dose, primarily driven by a decrease in bolus insulin requirements, was demonstrated. Liraglutide decreased non-significantly the odds for severe hypoglycemia (OR=0.80, 95% CI 0.57-1.14, I2=0%), while it increased significantly the odds for gastrointestinal adverse events (for nausea, OR=4.70, 95% CI 3.68-6.00, I2=37%, and for vomiting, OR=2.50, 95% CI 1.54-4.72, I2=27%). A significant increase in heart rate was also demonstrated. No association with diabetic ketoacidosis or malignancies was identified. CONCLUSION In patients with T1D, liraglutide might prove be an adjunct to insulin, improving glycemic control, inducing body weight loss and decreasing exogenous insulin requirements and severe hypoglycemia.
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Affiliation(s)
- Patoulias Dimitrios
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Doumas Michael
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
- VAMC and George Washington University, Washington, DC, United States
| | - Kotsis Vasilios
- Third Department of Internal Medicine, General Hospital "Papageorgiou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stavropoulos Konstantinos
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Imprialos Konstantinos
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Zografou Ioanna
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Petidis Konstantinos
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Bakatselos Spyridon
- First Department of Internal Medicine, General Hospital "Hippokration", Thessaloniki, Greece
| | - Karagiannis Asterios
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
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Janssens B, Caerels S, Mathieu C. SGLT inhibitors in type 1 diabetes: weighing efficacy and side effects. Ther Adv Endocrinol Metab 2020; 11:2042018820938545. [PMID: 32782777 PMCID: PMC7383636 DOI: 10.1177/2042018820938545] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/08/2020] [Indexed: 01/11/2023] Open
Abstract
Even before sodium-glucose cotransporter inhibitors (SGLTi) became popular agents for the treatment of people with type 2 diabetes (T2DM), clinicians had explored their potential as adjunct therapies in type 1 diabetes (T1DM). Several trials have demonstrated improved glycemic control (compared with placebo) and a decrease in glucose variability with a clinically relevant increase of time in range. In addition, weight loss and decreased systolic blood pressure are observed. The magnitude of the effects observed depends on the type of SGLTi, the dose administrated, and the duration of observation in the studies. As seen in T2DM, there was an increase in the risk of urogenital mycotic infections, but no increase in the risk of severe hypoglycemia. However, concerns arose regarding an increase in incidence of diabetic ketoacidosis. Mitigation strategies, including careful patient selection, extensive education of patients and (para)medical personnel, adequate insulin dose titration, and the adoption of a ketone-centered approach, are suggested. In different areas of the world, SGLTi are approved for use in T1DM with restrictions concerning patient selection and SGLTi dose. Real-world data on the effect of introduction of SGLTi in people with T1DM will yield insight on the robustness of glycemic effects over time, and allow us to determine whether the positive risk-benefit profile observed in clinical trials can be translated to the real world.
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Affiliation(s)
- Birgit Janssens
- Endocrinology BE, KU Leuven University Hospitals Leuven, Leuven, Vlaams Brabant, Belgium
| | - Simon Caerels
- Endocrinology BE, KU Leuven University Hospitals Leuven, Leuven, Vlaams Brabant, Belgium
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Wang Y, Lou Y, Wang J, Li D, Chen H, Zheng T, Xia C, Song X, Dong T, Li J, Li J, Liu H. Design, synthesis and biological evaluation of 6-deoxy O-spiroketal C-arylglucosides as novel renal sodium-dependent glucose cotransporter 2 (SGLT2) inhibitors for the treatment of type 2 diabetes. Eur J Med Chem 2019; 180:398-416. [DOI: 10.1016/j.ejmech.2019.07.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/09/2019] [Accepted: 07/09/2019] [Indexed: 12/25/2022]
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Lu J, Tang L, Meng H, Zhao J, Liang Y. Effects of sodium-glucose cotransporter (SGLT) inhibitors in addition to insulin therapy on glucose control and safety outcomes in adults with type 1 diabetes: A meta-analysis of randomized controlled trials. Diabetes Metab Res Rev 2019; 35:e3169. [PMID: 30974510 DOI: 10.1002/dmrr.3169] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/22/2019] [Accepted: 04/09/2019] [Indexed: 12/11/2022]
Abstract
Sodium-glucose cotransporter (SGLT) inhibitors added to insulin therapy have been proposed as treatment strategy for type 1 diabetes (T1D). We thus conducted a meta-analysis of randomized controlled trials (RCTs) to assess the efficacy and adverse effects of this combination in T1D. We searched the PubMed, EMBASE, and Cochrane Library databases and ClinicalTrials.gov for RCTs. Statistical analyses were performed using STATA 15. Ten eligible placebo-controlled trials involving 5961 patients were included. Compared with placebo, SGLT inhibitors were associated with a reduction in HbA1c of -0.39% (95% CI, -0.43 to -0.36), an improved mean amplitude of glucose excursion (MAGE) of -14.81 mg/dL (95% CI, -19.08 to -10.54), and a reduction in body weight of -3.47% (95% CI, -3.78 to -3.16), as well as no increased relative risk of hypoglycaemia (1.01; 95% CI, 0.99-1.02) or severe hypoglycaemia (0.91; 95% CI, 0.77-1.07). SGLT inhibitors decreased fasting plasma glucose and insulin requirement but increased the risk of genital infection (3.57; 95% CI, 2.97-4.29) and diabetic ketoacidosis (3.11; 95% CI, 2.11-4.58). However, the very low dose empagliflozin (2.5 mg) did not increase the risk of diabetic ketoacidosis (risk ratio [RR] 0.67; 95% CI, 0.11-3.95). SGLT inhibitors had no effect on overall adverse events, urinary tract infection, or bone fracture but slightly increased the risk of serious adverse events (1.35; 95% CI, 1.16-1.58), severe adverse events (1.84; 95% CI, 1.20-2.84), adverse events leading to discontinuation (1.50; 95% CI, 1.22-1.84), drug-related adverse events (1.78; 95% CI, 1.44-2.19), and diarrhoea (1.54; 95% CI, 1.15-2.05). Although adverse events exist, the available data provide evidence that the combination of SGLT inhibitors with basal insulin treatment is beneficial in patients with T1D.
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Affiliation(s)
- Jingli Lu
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijuan Tang
- Department of Medical Administration, Chengdu Women's and Children's Central Hospital, Chengdu, China
| | - Haiyang Meng
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junjie Zhao
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan Liang
- Department of Pharmacy, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Perkins BA, Rosenstock J, Skyler JS, Laffel LM, Cherney DZ, Mathieu C, Pang C, Wood R, Kinduryte O, George JT, Marquard J, Soleymanlou N. Exploring Patient Preferences for Adjunct-to-Insulin Therapy in Type 1 Diabetes. Diabetes Care 2019; 42:1716-1723. [PMID: 31177179 PMCID: PMC6973543 DOI: 10.2337/dc19-0548] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/30/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE While sodium-glucose cotransporter inhibitor (SGLTi) therapy has been evaluated in type 1 diabetes (T1D) trials, patient reactions to benefits and risks are unknown. Using established methodology, we evaluated patient preferences for different adjunct-to-insulin therapy options in T1D. RESEARCH DESIGN AND METHODS An online survey, completed by 701 respondents with T1D (231 U.S., 242 Canada, and 228 Germany), used conjoint analysis to present six hypothetical, masked, pairwise drug profile choices composed of different benefit-risk attributes and effect ranges. Data used in analyses were derived from actual phase 3 trials of a low-dose SGLTi (comparable to oral empagliflozin 2.5 mg q.d.), a high-dose SGLTi (comparable to oral sotagliflozin 400 mg q.d.), and an available adjunct-to-insulin therapy (comparable to subcutaneous pramlintide 60 μg t.i.d.). RESULTS Conjoint analysis identified diabetic ketoacidosis risk as most important to patients (23% relative score; z test, P < 0.05); ranked second were HbA1c reduction (14%), risk of severe hypoglycemia (13%), oral versus injectable treatment (12%), and risk of genital infection (12%). Next was risk of nausea (11%), followed by weight reduction (8%) and the risk of diarrhea (7%). A low-dose SGLTi drug profile was identified by conjoint analysis as the top patient preference (83% of participants; z test, P < 0.05) versus high-dose SGLTi (8%) or pramlintide (9%). Separate from conjoint analysis, when respondents were asked to choose their preferred adjunct-to-insulin therapy (masked to drug name/dose), 69%, 17%, 6%, and 9% of respondents chose low-dose SGLTi, high-dose SGLTi, pramlintide, and insulin therapy alone, respectively. CONCLUSIONS Low-dose SGLTi profile was the favored adjunct-to-insulin therapy by persons with T1D.
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Affiliation(s)
- Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, and Division of Endocrinology and Metabolism, University of Toronto, Toronto, Canada
| | | | - Jay S Skyler
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Lori M Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - David Z Cherney
- Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, University Hospital Leuven, Leuven, Belgium
| | | | | | - Ona Kinduryte
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | - Jan Marquard
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
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Li K, Xu G. Safety and efficacy of sodium glucose co-transporter 2 inhibitors combined with insulin in adults with type 1 diabetes: A meta-analysis of randomized controlled trials. J Diabetes 2019; 11:645-655. [PMID: 30565398 DOI: 10.1111/1753-0407.12890] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 12/08/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The safety and efficacy of sodium glucose co-transporter 2 (SGLT2) inhibitors in a dose-dependent manner for type 1 diabetes mellitus (T1DM) are unclear. METHODS Randomized clinical trials (RCT) were searched from PubMed, EMBASE, the Cochrane Library, Web of Science and ClinicalTrials until August 2018. RESULTS Thirteen RCT with 5397 participants were included. SGLT2 inhibitors were proved to be effective in glycemic control and weight loss in T1DM. In the subgroups of different doses, SGLT2 inhibitors exhibited reductions in glycated haemoglobin, bodyweight, fasting plasma glucose, mean daily glucose, basal insulin dose, bolus insulin dose, estimated glomerular filtration rate and systolic blood pressure, and elevations in the mean amplitude of glucose excursions, and percentage of time in target glucose range in a dose-dependent manner. Reductions in total insulin dose and urinary glucose excretion were dose-independent. SGLT2 inhibitors did not induce hypoglycemia, severe hypoglycemia, cardiovascular events, bone fracture and all-cause mortality, but increased the risk of adverse events (AE), adverse events related to the drug treatment, infections, diabetic ketoacidosis (DKA) and renal disease correlated with dosage. CONCLUSIONS SGLT2 inhibitors in high and moderate doses can achieve a better outcome on efficacy, but may induce a higher risk of adverse events, especially DKA.
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Affiliation(s)
- Kexin Li
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Jiangxi, China
- Grade 2015, Joint Programme of Nanchang University and Queen Mary University of London, Nanchang University, Jiangxi, China
| | - Gaosi Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Jiangxi, China
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Abstract
Type 1 diabetes mellitus (T1DM) is associated with premature cardiovascular disease (CVD), but the underlying mechanisms remain poorly understood. The American Diabetes Association and the European Association for the Study of Diabetes recently updated their position statement on the management of type 2 diabetes mellitus (T2DM) to include additional focus on cardiovascular risk; improved management of risk factors in T1DM is also needed. There are important differences in the pathophysiology of CVD in T1DM and T2DM. Hyperglycaemia appears to have a more profound effect on cardiovascular risk in T1DM than T2DM, and other risk factors appear to cause a synergistic rather than additive effect, so achievement of treatment targets for all recognized risk factors is crucial to reducing cardiovascular risk. Here we discuss the evidence for addressing established cardiovascular risk factors, candidate biomarkers and surrogate measurements, and possible interventions.
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Affiliation(s)
- Jonathan Schofield
- Manchester Diabetes Centre, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK.
- Cardiovascular Research Group, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9WU, UK.
| | - Jan Ho
- Cardiovascular Research Group, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9WU, UK
- Cardiovascular Trials Unit, University Department of Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Handrean Soran
- Cardiovascular Research Group, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9WU, UK
- Cardiovascular Trials Unit, University Department of Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
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Ji L, Liu Y, Miao H, Xie Y, Yang M, Wang W, Mu Y, Yan P, Pan S, Lauring B, Liu S, Huyck S, Qiu Y, Terra SG. Safety and efficacy of ertugliflozin in Asian patients with type 2 diabetes mellitus inadequately controlled with metformin monotherapy: VERTIS Asia. Diabetes Obes Metab 2019; 21:1474-1482. [PMID: 30830724 PMCID: PMC7379575 DOI: 10.1111/dom.13681] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/15/2019] [Accepted: 02/28/2019] [Indexed: 12/28/2022]
Abstract
AIM Phase III, randomized, double-blind study evaluating the efficacy and safety of ertugliflozin in Asian patients with type 2 diabetes mellitus (T2DM) inadequately controlled on metformin, including evaluation in the China subpopulation. MATERIALS AND METHODS A 26-week, double-blind study of 506 Asian patients (80.2% from mainland China), randomized 1:1:1 to placebo, ertugliflozin 5- or 15 mg, was performed. Primary endpoint was change from baseline in HbA1c at week 26. Secondary endpoints were change from baseline at week 26 in fasting plasma glucose (FPG), body weight (BW), systolic/diastolic blood pressure (SBP/DBP), and proportion of patients with HbA1c <7.0%. Hypotheses for the primary endpoint and FPG and BW secondary endpoints were tested in the China subpopulation. RESULTS At week 26, least squares mean (95% CI) change from baseline HbA1c was significantly greater with ertugliflozin 5- and 15 mg versus placebo: -1.0% (-1.1, -0.9), -0.9% (-1.0, -0.8), -0.2% (-0.3, -0.1), respectively. Ertugliflozin significantly reduced FPG, BW and SBP. Reductions in DBP with ertugliflozin were not significant. At week 26, 16.2%, 38.2% and 40.8% of patients had HbA1c <7.0% with placebo, ertugliflozin 5- and 15 mg, respectively. 59.3%, 56.5% and 53.3% of patients experienced adverse events with placebo, ertugliflozin 5- and 15 mg, respectively. Incidence of symptomatic hypoglycaemia was higher for ertugliflozin 15 mg vs placebo. Results in the China subpopulation were consistent. CONCLUSIONS Ertugliflozin significantly improved glycaemic control and reduced BW and SBP in Asian patients with T2DM. Ertugliflozin was generally well-tolerated. Results in the China subpopulation were consistent with the overall population. ClinicalTrials.gov: NCT02630706.
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Affiliation(s)
- Linong Ji
- Peking University People's HospitalBeijingChina
| | - Yanmei Liu
- Yancheng First People's HospitalYanchengChina
| | - Heng Miao
- The Second Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Yongli Xie
- Pingxiang People's HospitalPingxiangChina
| | | | - Wei Wang
- Pfizer (China) R&D Co.ShanghaiChina
| | | | - Ping Yan
- Pfizer (China) R&D Co.ShanghaiChina
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Nally LM, Sherr JL, Van Name MA, Patel AD, Tamborlane WV. Pharmacologic treatment options for type 1 diabetes: what's new? Expert Rev Clin Pharmacol 2019; 12:471-479. [PMID: 30892094 DOI: 10.1080/17512433.2019.1597705] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The expanding variety of insulins, including biosynthetic human insulin and rapid and long-acting insulin analogs, have dramatically transformed the management of type 1 diabetes (T1D) over the past 25 years. Moreover, increasing interest in the use of novel drugs developed for the treatment of type 2 diabetes (T2D) as adjunctive therapies for T1D remains a work in progress. Areas Covered: We reviewed articles published up to December 2018 in PubMed and ClinicalTrials.gov for recent developments in the pharmacologic treatment of T1D, including inhaled insulin, ultrafast and ultralong-acting insulins and adjunctive therapies including pramlintide, metformin, GLP-1 receptor agonists, DPP-4 inhibitors, SGLT-2, and SGLT1/2 inhibitors. Expert Opinion: With the creation of ultrafast-acting insulin analogs and very prolonged duration of action of basal insulins, it is possible to more closely mimic physiologic insulin secretion. Adjunctive therapies, likewise, may also overcome some of the abnormal physiology that is a hallmark of T1D. Therefore, individualized consideration of the efficacy of these agents must be measured alongside the potential adverse effects when choosing an adjunctive therapy.
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Affiliation(s)
- Laura M Nally
- a Yale Children's Diabetes Program , Yale University School of Medicine , New Haven , CT , USA
| | - Jennifer L Sherr
- a Yale Children's Diabetes Program , Yale University School of Medicine , New Haven , CT , USA
| | - Michelle A Van Name
- a Yale Children's Diabetes Program , Yale University School of Medicine , New Haven , CT , USA
| | - Anisha D Patel
- a Yale Children's Diabetes Program , Yale University School of Medicine , New Haven , CT , USA
| | - William V Tamborlane
- a Yale Children's Diabetes Program , Yale University School of Medicine , New Haven , CT , USA
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Musso G, Gambino R, Cassader M, Paschetta E. Efficacy and safety of dual SGLT 1/2 inhibitor sotagliflozin in type 1 diabetes: meta-analysis of randomised controlled trials. BMJ 2019; 365:l1328. [PMID: 30967375 PMCID: PMC6454301 DOI: 10.1136/bmj.l1328] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of dual sodium glucose cotransporter (SGLT) 1/2 inhibitor sotagliflozin in type 1 diabetes mellitus. DESIGN Meta-analysis of randomised controlled trials. DATA SOURCES Medline; Cochrane Library; Embase; international meeting abstracts; international and national clinical trial registries; and websites of US, European, and Japanese regulatory authorities, up to 10 January 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials evaluating the effect of sotagliflozin versus active comparators or placebo on glycaemic and non-glycaemic outcomes and on adverse events in type 1 diabetes in participants older than 18. Three reviewers extracted data for study characteristics, outcomes of interest, and risk of bias and summarised strength of evidence using the grading of recommendations assessment, development, and evaluation approach. Main outcomes were pooled using random effects models. RESULTS Of 739 records identified, six randomised placebo controlled trials (n=3238, duration 4-52 weeks) were included. Sotagliflozin reduced levels of glycated haemoglobin (HbA1c; weighted mean difference -0.34% (95% confidence interval -0.41% to -0.27%), P<0.001); fasting plasma glucose (-16.98 mg/dL, -22.1 to -11.9; 1 mg/dL=0.0555 mmol/L) and two hour-postprandial plasma glucose (-39.2 mg/dL, -50.4 to -28.1); and daily total, basal, and bolus insulin dose (-8.99%, -10.93% to -7.05%; -8.03%, -10.14% to -5.93%; -9.14%, -12.17% to -6.12%; respectively). Sotagliflozin improved time in range (weighted mean difference 9.73%, 6.66% to 12.81%) and other continuous glucose monitoring parameters, and reduced body weight (-3.54%, -3.98% to -3.09%), systolic blood pressure (-3.85 mm Hg, -4.76 to -2.93), and albuminuria (albumin:creatinine ratio -14.57 mg/g, -26.87 to -2.28). Sotagliflozin reduced hypoglycaemia (weighted mean difference -9.09 events per patient year, -13.82 to -4.36) and severe hypoglycaemia (relative risk 0.69, 0.49 to 0.98). However, the drug increased the risk of ketoacidosis (relative risk 3.93, 1.94 to 7.96), genital tract infections (3.12, 2.14 to 4.54), diarrhoea (1.50, 1.08 to 2.10), and volume depletion events (2.19, 1.10 to 4.36). Initial HbA1c and basal insulin dose adjustment were associated with the risk of diabetic ketoacidosis. A sotagliflozin dose of 400 mg/day was associated with a greater improvement in most glycaemic and non-glycaemic outcomes than the 200 mg/day dose, without increasing the risk of adverse events. The quality of evidence was high to moderate for most outcomes, but low for major adverse cardiovascular events and all cause death. The relatively short duration of trials prevented assessment of long term outcomes. CONCLUSIONS In type 1 diabetes, sotagliflozin improves glycaemic and non-glycaemic outcomes and reduces hypoglycaemia rate and severe hypoglycaemia. The risk of diabetic ketoacidosis could be minimised by appropriate patient selection and down-titration of the basal insulin dose.
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Affiliation(s)
- Giovanni Musso
- Humanitas University Gradenigo Hospital, 8 Corso Regina Margherita, 10132 Turin, Italy
| | - Roberto Gambino
- Laboratory of Diabetes and Metabolic Disorders, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Maurizio Cassader
- Laboratory of Diabetes and Metabolic Disorders, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Elena Paschetta
- Humanitas University Gradenigo Hospital, 8 Corso Regina Margherita, 10132 Turin, Italy
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Biester T, Kordonouri O, Danne T. Beyond type 2 diabetes: sodium glucose co-transporter-inhibition in type 1 diabetes. Diabetes Obes Metab 2019; 21 Suppl 2:53-61. [PMID: 31081591 DOI: 10.1111/dom.13659] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 12/12/2022]
Abstract
Use of sodium glucose cotransporter (SGLT) inhibitors are a well-established therapeutic option in type 2 diabetes (T2D) with a variety of proven therapeutic benefits. They have become a pillar of current treatment guidelines. In type 1 diabetes (T1D), initial exploratory studies have shown benefits in glycemic control, weight control, and cardiovascular risk parameters, leading to trials aiming for regulatory submission with several agents. Results from four 1-year trials, which included a total of 3052 patients, are now available, demonstrating promising findings that target the unmet needs of patients with T1D with a novel insulin-independent adjunct therapy. However, these positive effects must be balanced against the risks associated with this class of drugs. Specifically, current T1D studies have shown an increased risk of diabetic ketoacidosis (DKA), which, in some cases, presented with only slightly elevated glucose levels. While this complication may be clinically manageable once detected, the metabolic shift towards ketogenesis associated with this class of agents mandates appropriate patient selection. Currently, there are no validated tools for DKA risk assessment. Although the experience gained in studies and off-label use provides some indication for appropriate patient selection, this would have to be evaluated closely in the event that these drugs would receive regulatory approval. Risk mitigation includes training in ketone measurement (preferably as blood β-hydroxybutyrate testing), teaching the concept of euglycemic DKA, and providing a clear treatment algorithm to avoid progression of ketosis to full-blown DKA. Because similar unmet needs also exist in pediatric population studies, risk mitigation in youth should be initiated as well to allow an evidence-based, risk-benefit assessment in this vulnerable population.
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Affiliation(s)
- Torben Biester
- Diabetes Center for Children and Adolescents, AUF DER BULT, Hannover, Germany
| | - Olga Kordonouri
- Diabetes Center for Children and Adolescents, AUF DER BULT, Hannover, Germany
| | - Thomas Danne
- Diabetes Center for Children and Adolescents, AUF DER BULT, Hannover, Germany
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Ogawa W, Hirota Y. Sodium-glucose cotransporter 2 inhibitor-associated diabetic ketoacidosis in patients with type 1 diabetes: Metabolic imbalance as an underlying mechanism. J Diabetes Investig 2019; 10:879-882. [PMID: 30768861 PMCID: PMC6627165 DOI: 10.1111/jdi.13026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
For type 1 diabetes patients with inadequate glycemic control, one treatment option is to increase the insulin dose (scenario 1), which should not give rise to a “metabolic imbalance.” A second option is additional treatment with a sodium–glucose cotransporter 2 inhibitor, which might lead to a “metabolic imbalance” (scenario 2). A reduction in insulin dose in addition to administration of a sodium–glucose cotransporter 2 inhibitor might further increase the “metabolic imbalance” (scenario 3).![]()
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Affiliation(s)
- Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yushi Hirota
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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