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Scheen AJ. Underuse of GLP-1 receptor agonists in the management of type 2 diabetes despite a favorable benefit-safety profile. Expert Opin Drug Saf 2024; 23:797-810. [PMID: 38738549 DOI: 10.1080/14740338.2024.2354885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 05/09/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Patients with type 2 diabetes (T2DM) are at high risk of atherosclerotic cardiovascular disease (ASCVD) and cardiovascular death. Cardiovascular protection is a key objective in T2DM. AREAS COVERED Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have proven their efficacy in reducing major cardiovascular events in high-risk patients with T2DM in placebo-controlled trials, a finding confirmed in observational studies compared with other glucose-lowering agents. Overall, GLP-1RAs have a good safety profile associated with a favorable benefit/risk ratio for the management of T2DM, even if their cost-effectiveness might be questionable. International guidelines recommend GLP-1RAs as preferred glucose-lowering agents in patients with ASCVD and as a valuable alternative in overweight/obese patients with T2DM. However, real-life studies worldwide revealed that only a minority of patients receive a GLP-1RA, despite a positive trend for increased prescriptions in recent years. Surprisingly, however, fewer patients with established ASCVD are treated with these cardioprotective antihyperglycemic agents versus patients without ASCVD. EXPERT OPINION The reasons for GLP-1RA underuse in clinical practice are multiple. Multifaceted and coordinated interventions targeting all actors of the health-care system must be implemented to stimulate the adoption of GLP-1RAs as part of routine cardiovascular care among patients with T2DM, especially in those with ASCVD.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, CHU Liège, Liège, Belgium
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium
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Alshaya OA, Korayem GB, Alghwainm M, Alyami W, Alotaibi A, Alyami MS, Almohammed OA. The prevalence of cardiovascular diseases, chronic kidney disease, and obesity in patients with type 2 diabetes mellitus and the description of concurrent treatments: A two-center retrospective cross-sectional study in Saudi Arabia. Saudi Pharm J 2024; 32:102054. [PMID: 38590611 PMCID: PMC10999870 DOI: 10.1016/j.jsps.2024.102054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/27/2024] [Indexed: 04/10/2024] Open
Abstract
Background Atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), chronic kidney disease (CKD), and obesity are associated with increased morbidity and mortality in patients with type 2 diabetes mellitus (T2DM). Nonetheless, their prevalence among patients with T2DM in Saudi Arabia (SA) remains unknown. As current guidelines recommend, these comorbidities require adding certain antidiabetic agents with cardiorenal benefits. However, the prescribers' adherence to these recommendations remains unclear. Methods A two-center retrospective cross-sectional study was conducted including adult patients (≥18 years) with T2DM admitted to hospital or seen at outpatient clinics between January and December 2020. Patients were classified into two groups based on the presence or absence of ASCVD. Patients with no prior ASCVD history were further classified based on the 10-year ASCVD risk estimation. Endpoints of interest included the prevalence of ASCVD, HF, CKD, and obesity in patients with T2DM. We also evaluated the characteristics of the utilized antidiabetic agents, statin, and aspirin therapies.. Results Of the 1,218 included patients with T2DM, the majority were female (57.0 %), and aged 45-64 years (53.0 %) with a mean age of 59.3 ± 13.1 years. Hypertension and dyslipidemia were the most prevalent comorbidities (67.7 % and 69.0 %, respectively). Among all patients, 18.6 % had an established ASCVD and the prevalence of HF, CKD, and obesity were 5.1 %, 8.7 %, and 58.3 %, respectively. The most common types of ASCVD witnessed were revascularization (42.3 %), myocardial infarction (36.6 %), and stroke (33.9 %); with an increased prevalence of ASCVD as the age increases (52.8 % at age ≥ 65 years). In the non-ASCVD group, the 10-year ASCVD risk was intermediate or high in 62.7 % of these patients. The rates of utilization of guidelines-recommended therapies were 83.6 % for metformin, 9.4 % for GLP-1 RA, 10.8 % for SGLT2i, 35.2 % for aspirin alone or in combination with clopidogrel, and 79.7 % for statin therapy. Conclusions ASCVD, HF, CKD, and obesity are common complications in patients with T2DM in SA, with low overall utilization of the recommended guidelines-recommended medical therapies. Multimodal strategies should be utilized to assess T2DM and its complications, and to improve prescribers' adherence to guidelines-recommended therapies.
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Affiliation(s)
- Omar A. Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ghazwa B. Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University P.O.Box 84428, Riyadh 11671, Saudi Arabia
| | - Munirah Alghwainm
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Wed Alyami
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Albandari Alotaibi
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Majed S. Alyami
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Omar A. Almohammed
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Milder TY, Stocker SL, Baysari MT, Day RO, Greenfield JR. 'We are somehow fixated on this being a diabetes drug': a qualitative study exploring the views of cardiologists and nephrologists about sodium-glucose cotransporter 2 inhibitor initiation. Intern Med J 2024; 54:559-567. [PMID: 37548317 DOI: 10.1111/imj.16203] [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: 05/05/2023] [Accepted: 07/11/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are now indicated for heart failure and chronic kidney disease (CKD), irrespective of the presence of diabetes. Hence, cardiologists and nephrologists have an important role in initiating these drugs. AIMS To explore cardiologists' and nephrologists' perspectives regarding initiating SGLT2i and their safety monitoring practices when initiating SGLT2i. METHODS Purposive and snowball approaches were used to recruit participants working in diverse areas in New South Wales, Australia. Semi-structured interviews were conducted with 12 cardiologists and 12 nephrologists. Interviews were conducted until thematic saturation was reached. Emergent themes were identified from transcripts. An iterative general inductive approach was used for data analysis. RESULTS There was a reluctance amongst most non-heart-failure subspecialist cardiologists to initiate SGLT2i. Reasons included the perception of SGLT2i as diabetes drugs, concern about side effects, lack of experience and issues with follow-up. In contrast, nephrologists reported feeling confident to initiate SGLT2i. Nephrologists varied in their opinions about the severity of CKD at which SGLT2i initiation was reasonable and monitoring of renal function following initiation. Government subsidisation was an important factor in the decision to prescribe SGLT2i to people without diabetes. CONCLUSIONS Our findings highlight the complex transition from the perception of SGLT2i as diabetes drugs to cardiometabolic and reno-protective agents. Interdisciplinary collaboration may enable greater confidence amongst specialists to initiate SGLT2i, including in patients with CKD. Additionally, there is a need for clear and detailed guidance about SGLT2i prescription in patients with renal dysfunction and renal function monitoring following SGLT2i initiation.
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Affiliation(s)
- Tamara Y Milder
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, New South Wales, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia
- Clinical Science Pillar, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, New South Wales, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Melissa T Baysari
- Discipline of Biomedical Informatics and Digital Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, New South Wales, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, New South Wales, Australia
- Clinical Science Pillar, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Clinical Medicine, UNSW Medicine & Health, St Vincent's Healthcare Clinical Campus, UNSW Sydney, Sydney, New South Wales, Australia
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Guan H, Tian J, Wang Y, Niu P, Zhang Y, Zhang Y, Fang X, Miao R, Yin R, Tong X. Advances in secondary prevention mechanisms of macrovascular complications in type 2 diabetes mellitus patients: a comprehensive review. Eur J Med Res 2024; 29:152. [PMID: 38438934 PMCID: PMC10910816 DOI: 10.1186/s40001-024-01739-1] [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: 12/04/2023] [Accepted: 02/21/2024] [Indexed: 03/06/2024] Open
Abstract
Type 2 diabetes mellitus (T2DM) poses a significant global health burden. This is particularly due to its macrovascular complications, such as coronary artery disease, peripheral vascular disease, and cerebrovascular disease, which have emerged as leading contributors to morbidity and mortality. This review comprehensively explores the pathophysiological mechanisms underlying these complications, protective strategies, and both existing and emerging secondary preventive measures. Furthermore, we delve into the applications of experimental models and methodologies in foundational research while also highlighting current research limitations and future directions. Specifically, we focus on the literature published post-2020 concerning the secondary prevention of macrovascular complications in patients with T2DM by conducting a targeted review of studies supported by robust evidence to offer a holistic perspective.
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Affiliation(s)
- Huifang Guan
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, 130117, China
| | - Jiaxing Tian
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
| | - Ying Wang
- College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, 130117, China
| | - Ping Niu
- Rehabilitation Department, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, 130021, China
| | - Yuxin Zhang
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Yanjiao Zhang
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Xinyi Fang
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
- Graduate College, Beijing University of Chinese Medicine, Beijing, China
| | - Runyu Miao
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
- Graduate College, Beijing University of Chinese Medicine, Beijing, China
| | - Ruiyang Yin
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Xiaolin Tong
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
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Neumiller JJ, St. Peter WL, Shubrook JH. Type 2 Diabetes and Chronic Kidney Disease: An Opportunity for Pharmacists to Improve Outcomes. J Clin Med 2024; 13:1367. [PMID: 38592214 PMCID: PMC10932148 DOI: 10.3390/jcm13051367] [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: 01/11/2024] [Revised: 02/13/2024] [Accepted: 02/17/2024] [Indexed: 04/10/2024] Open
Abstract
Chronic kidney disease (CKD) is an important contributor to end-stage kidney disease, cardiovascular disease, and death in people with type 2 diabetes (T2D), but current evidence suggests that diagnosis and treatment are often not optimized. This review examines gaps in care for patients with CKD and how pharmacist interventions can mitigate these gaps. We conducted a PubMed search for published articles reporting on real-world CKD management practice and compared the findings with current recommendations. We find that adherence to guidelines on screening for CKD in patients with T2D is poor with particularly low rates of testing for albuminuria. When CKD is diagnosed, the prescription of recommended heart-kidney protective therapies is underutilized, possibly due to issues around treatment complexity and safety concerns. Cost and access are barriers to the prescription of newer therapies and treatment is dependent on racial, ethnic, and socioeconomic factors. Rates of nephrologist referrals for difficult cases are low in part due to limitations of information and communication between specialties. We believe that pharmacists can play a vital role in improving outcomes for patients with CKD and T2D and support the cost-effective use of healthcare resources through the provision of comprehensive medication management as part of a multidisciplinary team. The Advancing Kidney Health through Optimal Medication Management initiative supports the involvement of pharmacists across healthcare systems to ensure that comprehensive medication management can be optimally implemented.
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Affiliation(s)
- Joshua J. Neumiller
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA 99210, USA
| | - Wendy L. St. Peter
- Department of Pharmaceutical Care & Health Systems, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Jay H. Shubrook
- Department of Clinical Sciences and Community Health, Touro University California, Vallejo, CA 94592, USA;
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Somaili M, Oraibia O, Darraj M, Hassan A, Moafa E, Kulaybi A, Shubayli S, Moafa R, Mghfori G, Jaafari A, Somily M. Assessment of Knowledge and Perception of Sodium-Glucose Co-transporter 2 (SGLT-2) Inhibitors Prescription among Physicians in Saudi Arabia. Curr Diabetes Rev 2024; 20:e060723218471. [PMID: 37415371 DOI: 10.2174/1573399820666230706125244] [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: 10/15/2022] [Revised: 05/20/2023] [Accepted: 05/27/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors are a new class of medications that have been proven to improve both glycemic control and cardio-renal outcomes. The knowledge, attitude, and perception toward their prescriptions in Jazan, Saudi Arabia, are still unknown. OBJECTIVE The study aimed to measure the level of knowledge and attitude toward sodium-glucose cotransporter 2 inhibitors prescription among physicians in the Jazan region, Saudi Arabia. METHODS Data analysis was performed using Statistical Package for the Social Sciences, SPSS 23rd version. Frequency and percentages were used to display categorical variables. Minimum, maximum, mean, and standard deviation were used to test numerical variables. Independent t-test and ANOVA test were both utilized to test the factors associated with knowledge and attitude toward the use of SGLT-2 inhibitors. RESULTS A total of 65 participants were included in the study. 26.2% had a low knowledge level, 30.8% had a moderate knowledge level, and 43.1% had a high knowledge level of sodium-glucose cotransporter 2 inhibitors. 9.2% had a low attitude level, 43.1% had a moderate attitude level, and 47.7% had a high attitude level toward sodium-glucose cotransporter 2 inhibitors. Age, professional status, years of experience, and specialty were significantly associated with attitude but not with the knowledge of sodium-glucose cotransporter 2 inhibitors prescription. CONCLUSION While the study cohort scored high in the knowledge and attitude domains of the survey, a large proportion failed to answer very essential questions in type 2 diabetes management. An educational awareness program needs to be carried out to strengthen the physicians' knowledge of SGLT2 inhibitors prescription.
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Affiliation(s)
- Mohammed Somaili
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | - Omar Oraibia
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | - Majed Darraj
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | - Amal Hassan
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | - Esaam Moafa
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | - Abdulrahman Kulaybi
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | - Sahar Shubayli
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | - Razan Moafa
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | - Ghadah Mghfori
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | - Afaf Jaafari
- Department of Internal Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
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Safaie N, Masoumi S, Alizadeh S, Mirzajanzadeh P, Nejabati HR, Hajiabbasi M, Alivirdiloo V, Basmenji NC, Derakhshi Radvar A, Majidi Z, Faridvand Y. SGLT2 inhibitors and AMPK: The road to cellular housekeeping? Cell Biochem Funct 2024; 42:e3922. [PMID: 38269506 DOI: 10.1002/cbf.3922] [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: 09/22/2023] [Revised: 12/20/2023] [Accepted: 12/29/2023] [Indexed: 01/26/2024]
Abstract
Sodium-glucose co-transporter-2 (SGLT2) inhibitors, known as Gliflozins, are a class of Glucose-lowering drugs in adults with type 2 diabetes (T2D) that induce glucosuria by blocking SGLT2 co-transporters in the proximal tubules. Several lines of evidence suggest that SGLT2 inhibitors regulate multiple mechanisms associated with the regulation of varying cellular pathways. The 5'-adenosine monophosphate-activated protein kinase (AMPK) pathway plays an important role in metabolic homeostasis by influencing cellular processes. Recently, it has been shown that SGLT2 inhibitors can affect the AMPK pathway in differing physiological and pathological ways, resulting in kidney, intestinal, cardiovascular, and liver protective effects. Additionally, they have therapeutic effects on nonalcoholic fatty liver disease and diabetes mellitus-associated complications. In this review, we summarize the results of studies of AMPK-associated therapeutic effects of SGLT2 inhibitors in different organelle functions.
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Affiliation(s)
- Nasser Safaie
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shahab Masoumi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Cardiovascular Fellowship, Vanderbilt University of Medical center, Nashville, Tennessee, USA
| | - Shaban Alizadeh
- Department of Hematology, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | | | - Vahid Alivirdiloo
- Ramsar Campus, Mazandaran University of Medical Sciences, Ramasr, Iran
| | | | | | - Ziba Majidi
- Department of Medical Laboratory Science, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Yousef Faridvand
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
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Scheen AJ. Bridging the gap in cardiovascular care in diabetic patients: are cardioprotective antihyperglycemic agents underutilized? Expert Rev Clin Pharmacol 2023; 16:1053-1062. [PMID: 37919944 DOI: 10.1080/17512433.2023.2279193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/31/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Atherosclerotic cardiovascular disease (ASCVD) and heart failure (HF) are two major complications of type 2 diabetes (T2DM). Cardiovascular protection is a key objective, yet not fully reached in clinical practice. AREAS COVERED Both glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT2is) have proven their efficacy in reducing major cardiovascular events in high-risk patients with T2DM and SGLT2is in reducing hospitalization for HF in placebo-controlled randomized trials. However, real-life studies worldwide revealed that only a minority of patients with T2DM receive either a GLP-1RA or an SGLT2i and surprisingly even less patients with established ASCVD or HF are treated with these cardioprotective antihyperglycemic agents. EXPERT OPINION Bridging the gap between evidence-based cardiovascular protection with GLP-1RAs and SGLT2is and their underuse in daily clinical practice in patients with T2DM at high risk is crucial from a public health viewpoint. However, the task appears hazardous and the goal not attained considering the current failure. Education of specialists/primary care physicians and patients is critical. Multifaceted and coordinated interventions involving all actors (physicians, patients and broadly health-care system) must be implemented to stimulate the adoption of these cardioprotective antihyperglycemic medications as part of routine cardiovascular care among patients with T2DM.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium
- Division of Diabetes, Nutrition and Metabolic Disorders, CHU Liège, Liège, Belgium
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Nee R, Yuan CM, Narva AS, Yan G, Norris KC. Overcoming barriers to implementing new guideline-directed therapies for chronic kidney disease. Nephrol Dial Transplant 2023; 38:532-541. [PMID: 36264305 PMCID: PMC9976771 DOI: 10.1093/ndt/gfac283] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Indexed: 11/13/2022] Open
Abstract
For the first time in many years, guideline-directed drug therapies have emerged that offer substantial cardiorenal benefits, improved quality of life and longevity in patients with chronic kidney disease (CKD) and type 2 diabetes. These treatment options include sodium-glucose cotransporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and glucagon-like peptide-1 receptor agonists. However, despite compelling evidence from multiple clinical trials, their uptake has been slow in routine clinical practice, reminiscent of the historical evolution of angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use. The delay in implementation of these evidence-based therapies highlights the many challenges to optimal CKD care, including: (i) clinical inertia; (ii) low CKD awareness; (iii) suboptimal kidney disease education among patients and providers; (iv) lack of patient and community engagement; (v) multimorbidity and polypharmacy; (vi) challenges in the primary care setting; (vii) fragmented CKD care; (viii) disparities in underserved populations; (ix) lack of public policy focused on health equity; and (x) high drug prices. These barriers to optimal cardiorenal outcomes can be ameliorated by a multifaceted approach, using the Chronic Care Model framework, to include patient and provider education, patient self-management programs, shared decision making, electronic clinical decision support tools, quality improvement initiatives, clear practice guidelines, multidisciplinary and collaborative care, provider accountability, and robust health information technology. It is incumbent on the global kidney community to take on a multidimensional perspective of CKD care by addressing patient-, community-, provider-, healthcare system- and policy-level barriers.
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Affiliation(s)
- Robert Nee
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Christina M Yuan
- Nephrology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA
- Department of Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Andrew S Narva
- College of Agriculture, Urban Sustainability and Environmental Studies, University of the District of Columbia, Washington, DC, USA
| | - Guofen Yan
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Keith C Norris
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
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10
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Song L, Wang X, Sun J, Hu X, Li H, Hu P, Liu D. A Model-Informed Approach to Accelerate the Clinical Development of Janagliflozin, an Innovative SGLT2 Inhibitor. Clin Pharmacokinet 2023; 62:505-518. [PMID: 36802026 DOI: 10.1007/s40262-022-01209-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 02/21/2023]
Abstract
AIM To apply model-informed drug development (MIDD) approach to support the decision making in drug development and accelerate the clinical development of janagliflozin, an orally selective SGLT2 inhibitor. METHOD We previously developed a mechanistic pharmacokinetic/pharmacodynamic (PK/PD) model of janagliflozin based on preclinical data to optimize dose design in the first-in-human (FIH) study. In the current study, we used clinical PK/PD data of the FIH study to validate the model and then simulate the PK/PD profiles of multiple ascending dosing (MAD) study in healthy subjects. Besides, we developed a population PK/PD model of janagliflozin to predict steady-state urinary glucose excretion (UGE [UGE,ss]) in healthy subjects in the Phase 1 stage. This model was subsequently used to simulate the UGE, ss in patients with type 2 diabetes mellitus (T2DM) based on a unified PD target (ΔUGEc) across healthy subjects and patients with T2DM. This unified PD target was estimated from our previous work of model-based meta-analysis (MBMA) for the same class of drugs. The model-simulated UGE,ss in patients with T2DM was validated by data from the clinical Phase 1e study. Finally, at the end of the Phase 1 study, we simulated the 24-week hemoglobin A1c (HbA1c) level in patients with T2DM of janagliflozin based on the quantitative UGE/FPG/HbA1c relationship informed by our previous MBMA study for the same class of drugs. RESULTS The pharmacologically active dose (PAD) levels of multiple ascending dosing (MAD) study were estimated to be 25, 50,100 mg once daily (QD) for 14 days based on the effective PD target of approximately 50 g daily UGE in healthy subjects. Besides, our previous MBMA analysis for the same class of drugs has provided a unified effective PD target of ΔUGEc approximately 0.5-0.6 g/(mg/dL) in both healthy subjects and patients with T2DM. In this study, the model-simulated steady-state ΔUGEc (ΔUGEc,ss) of janagliflozin in patients with T2DM were 0.52, 0.61 and 0.66 g/(mg/dL) for 25, 50, 100 mg QD dose levels. Finally, we estimated that HbA1c at 24 weeks would decrease 0.78 and 0.93 from baseline for the 25 and 50 mg QD dose groups. CONCLUSIONS The application of MIDD strategy adequately supported the decision making at each stage of janagliflozin development process. A waiver of Phase 2 study was successfully approved for janagliflozin based on these model-informed results and suggestions. This MIDD strategy of janagliflozin could be further utilized to support the clinical development of other SGLT2 inhibitors.
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Affiliation(s)
- Ling Song
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, 100191, China.,Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, 100191, China.,Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing, 100191, China
| | - Xiaoxu Wang
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, 100191, China.,Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, 100191, China
| | - Jingfang Sun
- Huisheng Bio-pharmaceutical Co., Ltd, Jilin, 135099, China
| | - Xinyu Hu
- Huisheng Bio-pharmaceutical Co., Ltd, Jilin, 135099, China
| | - Haiyan Li
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, 100191, China.,Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing, 100191, China
| | - Pei Hu
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital & Chinese Academy of Medical Sciences, Beijing, 100032, China.
| | - Dongyang Liu
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, 100191, China. .,Institute of Medical Innovation and Research, Peking University Third Hospital, Beijing, 100191, China. .,Clinical Pharmacology Research Center, Peking Union Medical College Hospital & Chinese Academy of Medical Sciences, Beijing, 100032, China.
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Korayem GB, Alshaya OA, Alghamdi AA, Alanazi SS, Almutib RT, Alsaileek M, Alrashidi A, Aldosari N, Bin Sheraim N, Al Yami MS, Almohammed OA. The prescribing pattern of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists in patient with type two diabetes mellitus: A two-center retrospective cross-sectional study. Front Public Health 2022; 10:1031306. [PMID: 36408008 PMCID: PMC9673169 DOI: 10.3389/fpubh.2022.1031306] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/11/2022] [Indexed: 01/29/2023] Open
Abstract
Background The use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) in patients with type 2 diabetes mellitus (T2DM) remains limited, especially in those with other compelling indications. Thus, this study aimed to describe the prescribing patterns of GLP-1-RA and SGLT2i in patients with T2DM and to determine the factors that affect the prescribing of these medications. Methods This multicenter retrospective cross-sectional study reviewed the electronic health records of adult patients diagnosed with T2DM who received care between January and December 2020. The patients were classified according to their compelling indications into "patients who are more likely" to benefit from SGLT2i or GLP-1 RA and "patients who are less likely" to benefit from them. They were then further categorized depending on whether these medications were prescribed. Results A total of 1,220 patients were included; most were female (56.9%). SGLT2i or GLP-1 RA were preferably prescribed in only 19% of the patients for reasons including BMI ≥ 27 kg/m2 (85.6%), uncontrolled T2DM (68.5%), high risk for ASCVD (23.9%), or established ASCVD (14%). The remaining 81.0% were underprescribed these agents. Patients at an older age or with a history of stroke or transient ischemic attack had higher odds of being underprescribed (OR 1.02; 95% CI: 1.01-1.03 and OR 2.86; 95% CI: 1.33-6.15), respectively. Conclusion The results concur with those of previous studies highlighting the underutilization of GLP-1 RA and SGLT2i in patients with T2DM but also with compelling indications. To optimize the use of GLP-1 RA and SGLT2i for their additional benefits, prescribers need to assess the benefits of using these agents in patients who would likely benefit from them, regardless of DM control.
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Affiliation(s)
- Ghazwa B. Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia,*Correspondence: Ghazwa B. Korayem
| | - Omar A. Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia,Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Albandari A. Alghamdi
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Shahad S. Alanazi
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Renad T. Almutib
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Mahdi Alsaileek
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdulrahman Alrashidi
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nasser Aldosari
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nader Bin Sheraim
- Pharmaceutical Care Services, King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Majed S. Al Yami
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia,Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Omar A. Almohammed
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia,Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Barrios V, Escobar C, Suarez C, Garcia-Moll X, Lozano F. Clinical Profile and Management of Patient Patients with Ischemic Heart Disease and/or Peripheral Artery Disease in Clinical Practice: The APALUSA Study. J Clin Med 2022; 11:jcm11123554. [PMID: 35743622 PMCID: PMC9224728 DOI: 10.3390/jcm11123554] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 02/01/2023] Open
Abstract
This study was aimed to ascertain the clinical profile and management of patients with ischemic heart disease (IHD) and/or peripheral artery disease (PAD). In this observational and cross-sectional study developed in 80 hospitals throughout Spain, consecutive adults with stable IHD and/or PAD were included. A total of 1089 patients were analyzed, of whom 65.3% had only IHD, 17.8% PAD and 16.9% both. A total of 80.6% were taking only one antiplatelet agent, and 18.2% were on dual antiplatelet therapy (mainly aspirin/clopidogrel). Almost all patients were taking ≥1 lipid lowering drug, mainly moderate-to-high intensity statins. IHD patients took ezetimibe more commonly than PAD (43.9% vs. 12.9%; p < 0.001). There were more patients with IHD that achieved blood pressure targets compared to PAD (<140/90 mmHg: 67.9% vs. 43.0%; p < 0.001; <130/80 mmHg: 34.1% vs. 15.7%; p < 0.001), LDL-cholesterol (<70 mg/dL: 53.1% vs. 41.5%; p = 0.033; <55 mg/dL: 26.5% vs. 16.0%; p = 0.025), and diabetes (HbA1c < 7%, with SGLT2i/GLP1-RA: 21.7% vs. 8.8%; p = 0.032). Modifications of antihypertensive agents and lipid-lowering therapy were performed in 69.0% and 82.3% of patients, respectively, without significant differences between groups. The use of SGLT2i/GLP1-RA was low. In conclusion, cardiovascular risk factors control remains poor among patients with IHD, PAD, or both. A higher use of combined therapy is warranted.
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Affiliation(s)
- Vivencio Barrios
- Cardiology Department, University Hospital Ramon y Cajal, 28034 Madrid, Spain
- Correspondence:
| | - Carlos Escobar
- Cardiology Department, University Hospital La Paz, 28046 Madrid, Spain;
| | - Carmen Suarez
- Internal Medicine Department, University Hospital la Princesa, 28006 Madrid, Spain;
| | - Xavier Garcia-Moll
- Cardiology Department, University Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain;
| | - Francisco Lozano
- Vascular Surgery Department, University Hospital Clínico, 37007 Salamanca, Spain;
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