Early combination versus initial metformin monotherapy in the management of newly diagnosed type 2 diabetes: An East Asian perspective

Molecular insights into Parkinson's disease and type 2 diabetes mellitus: Metformin's role and genetic pathways explored

Background To explore whether there is a bidirectional relationship between Parkinson's disease (PD) and type 2 diabetes mellitus (T2DM), study the common pathogenic mechanisms, screen relevant genes involved in the pathological process, and predict the potential targets of metformin (Met), so as to develop new therapeutic strategies. Method A two-sample Mendelian randomization (MR) analysis was conducted to analyze the correlation between PD and T2DM. Common confounding genes identified in both PD and T2DM datasets were subjected to GO and KEGG analysis, PPI network analysis, and Hub gene identification. qPCR was used to verify the expression of hub genes in an animal model of T2DM complicated with PD. Subsequently, the analysis focused on whether metformin alleviates the behavioral and pathological manifestations of PD aggravated by T2DM. The intersection of metformin with T2DM and PD targets was identified, and the core targets and signaling pathways were analyzed. Finally, molecular docking analysis was performed between metformin and core proteins to identify the docking sites. Result Through MR analysis, a positive correlation between PD and T2DM was identified, indicating a mutual causal relationship. The hub genes RAC1, TPM2, MGA, and DENND3 are up-regulated in animal models of T2DM with PD. Met targets intersecting with T2DM and PD were analyzed, revealing 17 and 21 intersecting genes respectively, involved in various pathways related to oxidative stress, immune, and inflammation. PPI analysis identified hub genes for T2DM (MMP9, NCF1, CYCS, EIF4E, SOD2) and PD (GFAP, VIM, MOCOS, EIF1, TH, ACTA2, CDC42). Animal models validated the expression of these genes and pathways. Molecular docking analysis explored Met's binding sites on proteins, with lower binding energies indicating greater stability. Conclusion This study contributes to a deeper understanding of the co pathogenesis of PD and T2DM, and provides new insights into the role of metformin in this disease.

Clinical effectiveness and cost-effectiveness of first-line early combination of dipeptidyl peptidase 4 inhibitors and metformin in patients with type 2 diabetes in Taiwan: A modelling study

AIMS

Early dipeptidyl peptidase-4 inhibitors and metformin (DPP4i-Met) combination has been shown to extend the time to treatment failure and provide better glycaemic control for newly diagnosed type 2 diabetes (T2D) patients; however, the long-term clinical and economic outcomes of early DPP4i-Met combination remain unknown. We seek to assess the comparative long-term clinical and cost-effectiveness of DPP4i-Met versus Met for treatment-naïve T2D patients with inadequately controlled HbA1c (i.e., ≥8.5%).

METHODS

The IQVIA CORE Diabetes Model was used to simulate the quality-adjusted life years (QALYs) and healthcare costs over a lifetime from Taiwan's National Health Insurance Administration's perspective, with both QALYs and costs discounted at 3% annually. Model inputs were taken from the analyses of Taiwanese or Asian populations. Primary outcomes included the number needed to treat (NNT) to prevent one case of a clinical event and the incremental cost-effectiveness ratios (ICERs). Costs are presented in 2023 US dollars.

RESULTS

Over 40 years of projection, Met-DPP4i-treated patients had fewer complications than those using Met alone (e.g., lowering the incidence of stroke by 2.21% [2.68, 1.74]). The NNT using DPP4i-Met versus Met alone to prevent one case of stroke, microalbuminuria, neuropathy and background retinopathy was 45, 135, 65 and 182, respectively. Such long-term benefits in reducing costly complications offset the higher treatment cost of DDP4i-Met versus Met ($5796 vs. $5484/person). As a result, using DPP4i-Met versus Met yielded 0.086 QALYs gained and savings of $489 for overall treatment-naïve T2D patients and 0.064 QALYs gained and savings of $714 for young-onset T2D patients.

CONCLUSIONS

Early DPP4i-Met provides long-term clinical and economic benefits compared to Met alone for newly diagnosed T2D patients, including those with young-onset T2D.

The effect of vildagliptin versus metformin on hepatic steatosis in type 2 diabetic patients: a randomized controlled trial

BACKGROUND

The risk of hepatic steatosis (HS) is elevated in patients with type 2 diabetes mellitus (T2D). Antidiabetic medications may contribute to the prevention or treatment of HS. This study aimed to compare the effects of vildagliptin and metformin on hepatic steatosis in newly diagnosed T2D patients, using the Hepatic Steatosis Index (HSI) and ultrasound grading.

METHODS

The study included 246 newly diagnosed T2D patients who were randomly assigned to two groups. The first group (117 patients) received 50 mg of vildagliptin orally twice daily. The second group (129 patients) received 500 mg of metformin orally twice daily with meals, and the dosage could be gradually increased by 500 mg per week, up to a maximum daily dose of 2000 mg. Baseline and 6-month follow-up assessments included fasting blood glucose (FBG), HbA1c, weight, body mass index (BMI), waist circumference (WC), hip circumference (HC), the Hepatic Steatosis Index (HSI), and hepatic steatosis grading via ultrasound.

RESULTS

Both groups showed significant improvements in FBG, HbA1c, weight, BMI, WC, HC, HSI, and ultrasound grading of hepatic steatosis from baseline to the 6-month follow-up (p < 0.001). The metformin group demonstrated significantly greater reductions in weight and BMI compared to the vildagliptin group (p = 0.001 and p = 0.009, respectively). However, there was no significant difference between the two groups in terms of hepatic steatosis improvement on ultrasound. Correlation analysis revealed that HSI was significantly associated with HbA1c, BMI, WC, and HC (p < 0.001 for all), as well as FBG (p = 0.008), but not with age. The lipid profile, particularly total cholesterol and LDL, was identified as a stronger predictor of hepatic steatosis, based on high AUC, sensitivity, and specificity values.

CONCLUSION

Both vildagliptin and metformin are effective in improving glycemic control in newly diagnosed T2D patients, as evidenced by reductions in FBG and HbA1c levels. Additionally, both drugs significantly reduced the HSI, body weight, and BMI, with metformin showing a more pronounced effect on weight and BMI. Both vildagliptin and metformin effectively decreased hepatic steatosis in T2D patients. Total cholesterol and LDL are important predictors of hepatic steatosis.

TRIAL REGISTRATION

Trial Registration ID: UMIN000055121, registered on 30/07/2024 (retrospectively registered).

The comparison of the antidiabetic effects of exenatide, empagliflozin, quercetin, and combination of the drugs in type 2 diabetic rats

BACKGROUND

Type 2 diabetes, a metabolic disease that involves extended treatment, is rapidly increasing in humans and animals worldwide.

OBJECTIVES

This study aimed to compare monotherapy and combined therapy of exenatide, empagliflozin, and quercetin in 67 Wistar Albino male rats.

METHODS

The animals were divided into the following seven groups: healthy control, diabetes control, diabetes + sham, diabetes + exenatide (10 μg/kg), diabetes + empagliflozin (50 mg/kg), diabetes + quercetin (50 mg/kg), and diabetes + combination treatment. The treatments were continued for 8 weeks.

RESULTS

At the end of the experiment, glucose and HbA1c levels decreased with all monotherapy treatments and the combination treatments, while insulin levels increased with exenatide and combined treatments. Adiponectin levels increased with empagliflozin, quercetin, and combined treatments, while leptin levels decreased only with combined treatments. All monotherapies caused an increase in total antioxidant levels. Exenatide and quercetin treatments reduced low-density lipoprotein (LDL) levels; therewithal, exenatide and combined treatments increased high-density lipoprotein (HDL) levels. Triglyceride levels decreased in all treatment groups. The homeostatic model assessment for insulin resistance (HOMA-IR) level decreased with the combined treatment; on the contrary, the homeostatic model assessment for β-cell activity (HOMA-β) level increased with empagliflozin, exenatide, and combined treatments.

CONCLUSION

In conclusion, the antidiabetic effects of exenatide were more pronounced than empagliflozin and quercetin, however, the combined treatment had better antidiabetic and antihyperlipidemic effects than monotherapies. Quercetin could be a supportive or food supplement antidiabetic agent. The exenatide treatment can be recommended for monotherapy in type 2 patients, and the combination of empagliflozin, exenatide, and quercetin may be effective in diabetic patients who need combined therapy.

Efficacy of metformin on different adipocytokines in type 2 diabetes mellitus patients

Background

Type 2 diabetes mellitus is a major medical condition that constitutes a significant financial burden on most healthcare systems.

Objective

The current research aimed to evaluate the antidiabetic, anti-inflammatory, and antihyperlipidemic effects of 500 mg metformin twice daily for 6 months on various adipocytokines in type 2 diabetes mellitus patients.

Patients and methods

The participants in this study were divided into three groups: the control, the untreated diabetic, and the metformin-treated diabetic groups.

Results and conclusion

Metformin treatment significantly improved the poor oral glucose tolerance and the lowered serum levels of insulin and C-peptide with subsequent better homeostatic model assessment for insulin resistance and sensitivity and β-cell function results. Moreover, metformin treatment significantly decreased the elevated serum levels of glycosylated hemoglobin, high, low, and very low-density lipoproteins, adipokines (visfatin and resistin), and retinol-binding protein-4 expression, with a significant increase in total cholesterol and triglycerides. Metformin also reduced the proinflammatory cytokine expressions (interleukin-1β, interferon-γ, and tumor-necrosis factor-α). In conclusion, metformin can alleviate adipocytokines through anti-inflammatory effects, synergizing with its antidiabetic actions.

Health and Productivity Benefits with Early Intensified Treatment in Patients with Type 2 Diabetes: Results from Korea

The available evidence suggests positive health outcomes associated with early treatment intensification in Type 2 diabetes mellitus (T2DM). Our study estimated the productivity effects arising from improved health correlated with early intensified treatment in T2DM in Korea. Using a recently published methodology and model, we investigated the association between early intensified treatment and the probability of experiencing fewer diabetes-related complication events. Treatment strategies leading to better health outcomes are expected to be associated with social value through increased participation in paid and unpaid work activities. Therefore, we translated the lower incidence of complications into monetary terms related to productivity for the Korean population. We quantified productivity by considering (a) absenteeism, (b) presenteeism, (c) permanent loss of labor force, and (d) activity restriction. Deterministic and probabilistic sensitivity analyses in the base case parameter were performed. Approximately, 1.7 thousand (standard deviation [SD] ±580 events) micro- and macrovascular complication events could potentially be avoided by early treatment intensification. This led to a societal gain attributed to increased productivity of 23 million USD (SD ± $8.2 million). This article demonstrates the likelihood of achieving better health and productivity through early intensified treatment in diabetes.

Glycaemic Control and Weight Reduction: A Narrative Review of New Therapies for Type 2 Diabetes

Early and intensive treatment of type 2 diabetes (T2D) has been associated with lower risk of diabetes-related complications. Control of overweight and obesity, which are strongly associated with T2D and many of its complications, is also key in the management of the disease. New therapies allow for individualised glycaemic control targets with greater safety. Thus, in patients with a higher cardiovascular and renal risk profile, current guidelines encourage early treatment with metformin together with glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose co-transporter-2 inhibitors with proven cardiovascular benefit. GLP-1 RAs combine highly efficacious glucose-lowering activity with a reduced risk of hypoglycaemia. Recently, tirzepatide, a first-in-class drug that activates both glucose-dependent insulinotropic polypeptide and GLP-1 receptors, has demonstrated very high efficacy in glycated haemoglobin (HbA1c) and weight reduction in clinical trials. Tirzepatide has the potential to help people with T2D reach recommended glycaemic and weight targets (HbA1c < 7% and > 5% weight reduction) and to allow some patients to reach HbA1c measurements close to normal physiological levels and substantial weight reduction. In 2022, tirzepatide was approved by the US Food and Drug Administration and the European Medicines Agency for treatment of people with T2D and is currently in development for chronic weight management.

Pathophysiology, phenotypes and management of type 2 diabetes mellitus in Indian and Chinese populations

Nearly half of all adults with type 2 diabetes mellitus (T2DM) live in India and China. These populations have an underlying predisposition to deficient insulin secretion, which has a key role in the pathogenesis of T2DM. Indian and Chinese people might be more susceptible to hepatic or skeletal muscle insulin resistance, respectively, than other populations, resulting in specific forms of insulin deficiency. Cluster-based phenotypic analyses demonstrate a higher frequency of severe insulin-deficient diabetes mellitus and younger ages at diagnosis, lower β-cell function, lower insulin resistance and lower BMI among Indian and Chinese people compared with European people. Individuals diagnosed earliest in life have the most aggressive course of disease and the highest risk of complications. These characteristics might contribute to distinctive responses to glucose-lowering medications. Incretin-based agents are particularly effective for lowering glucose levels in these populations; they enhance incretin-augmented insulin secretion and suppress glucagon secretion. Sodium-glucose cotransporter 2 inhibitors might also lower blood levels of glucose especially effectively among Asian people, while α-glucosidase inhibitors are better tolerated in east Asian populations versus other populations. Further research is needed to better characterize and address the pathophysiology and phenotypes of T2DM in Indian and Chinese populations, and to further develop individualized treatment strategies.

Obesity Pillars Roundtable: Obesity and East Asians

Background

Individuals from East Asia make up about 1/5th of the world's population. Individuals from South Asia with obesity are well-described to have increased susceptibility to cardiovascular disease (CVD) risk factors and increased risk of CVD events. Less well described are the adiposopathic effects of the disease of obesity among East Asians.

Methods

This roundtable discussion includes 3 obesity medicine specialists with experience in the clinical management of obesity among patients of East Asian descent. Included are citations regarding obesity and East Asians.

Results

In general, East Asians are at decreased risk for CVD compared to Whites and South Asians. However, compared to Whites, for the same body mass index, East Asians are at increased risk for metabolic diseases such as type 2 diabetes mellitus. Both obesity and type 2 diabetes mellitus are epidemics in East Asian countries. In this Roundtable, the panelists discuss East Asian nutrition and physical activity, with special attention given to Asian foods, especially rice. The panelists also discuss East Asian genetic predispositions for development of visceral adiposity, type 2 diabetes mellitus, as well as genetic predisposition to drug metabolism and potential drug and herbal interactions, as commonly encountered in patients with obesity. Finally, the panelists give summary tips for managing East Asian patients with obesity.

Conclusion

The three panelists of this roundtable describe their practical diagnostic processes and treatment plans for patients from East Asia, with an emphasis on a patient-centered approach to obesity in this unique population.

Bioactivity-guided separation of potential α-glycosidase inhibitor from clerodendranthus spicatus based on HSCCC coupled with molecular docking

Clerodendranthus Spicatus is a traditional Dais medi-edible plant and it has been proven to have good blood glucose-lowering efficacy. However, the material basis of Clerodendranthus Spicatus has not been clarified yet and therefore needs to be determined. In this paper, the effective ingredients of this medicine were purified by high-speed counter-current chromatography. Alongside, their potential hypoglycemic activity was determined by α-glucosidase inhibitory activities in vitro and molecular docking. Finally, five compounds were purified and identified as 2-caffeoyl-L-tartaric acid (1), N-(E)-caffeoyldopamine (2), rosmarinc acid (3), methyl rosmarinate (4), 6,7,8,3',4'-Pentamethoxyflavone (5). Examination of α-glucosidase inhibitory activity in vitro showed that 2-caffeoyl-L-tartaric acid and rosmarinic acid had a higher inhibitory activity than acarbose. Molecular docking indicated that the affinity energy of the identified compounds ranged from - 7.6 to - 8.6 kcal/mol, a more desirable result than acarbose (- 6.6 kcal/mol). Particularly, rosmarinc acid with the lowest affinity energy of - 8.6 kcal/mol was wrapped with 6 hydrogen bonds. Overall, α-glucosidase inhibitory activities and molecular docking suggested that rosmarinc acid was likely to be a promising hypoglycemic drug.

Early combination versus initial metformin monotherapy in the management of newly diagnosed type 2 diabetes: An East Asian perspective

Type 2 diabetes (T2D) in the East Asian population is characterized by phenotypes such as low body mass index, an index of β-cell dysfunction, and higher percentage of body fat, an index of insulin resistance. These phenotypes/pathologies may predispose people to early onset of diabetes with increased risk of stroke and renal disease. Less than 50% of patients with T2D in East Asia achieve glycaemic targets recommended by national or regional guidelines, which may be attributable to knowledge and/or implementation gaps. Herein, we review the latest evidence with special reference to East Asian patients with T2D and present arguments for the need to use early combination therapy to intensify glycaemic control. This strategy is supported by the 5-year worldwide VERIFY study, which reported better glycaemic durability in newly diagnosed patients with T2D with a mean HbA1c of 6.9% treated with early combination therapy of vildagliptin plus metformin versus those treated with initial metformin monotherapy followed by addition of vildagliptin only with worsening glycaemic control. This paradigm shift of early intensified treatment is now recommended by the American Diabetes Association and the European Association for the Study of Diabetes. In order to translate these evidence to practice, increased awareness and strengthening of the healthcare system are needed to diagnose and manage patients with T2D early for combination therapy.