Efficacy and safety of sitagliptin in elderly patients with type 2 diabetes mellitus

Efficacy and safety of sitagliptin treatment in older adults with moderately controlled type 2 diabetes: the STREAM study

Sitagliptin has been suggested as a treatment option for older adults with type 2 diabetes (T2D). However, no randomized controlled trial has been performed to evaluate the efficacy and safety of sitagliptin treatment in older Japanese patients with T2D. The STREAM study was a multicenter, open-label, randomized controlled trial. T2D outpatients aged 65-80 years with moderately controlled glycemic levels (HbA1c 7.4-10.4%) under lifestyle interventions without or with oral anti-diabetic drugs excluding DPP4 inhibitors or GLP-1 receptor agonists were recruited (n = 176). The participants were randomized into sitagliptin group (n = 88) who received sitagliptin as an initial or an additive anti-diabetic drug and control group (n = 88) who did not. The treatment goal was HbA1c level < 7.4%. Efficacy and safety during 12-month treatment period were investigated. The mean (± SD) ages were 70.6 ± 3.9 and 71.9 ± 4.4 years old in sitagliptin and control groups, respectively. According to a mixed-effects model analysis, average changes from baseline over the treatment period in fasting plasma glucose (FPG), HbA1c, and glycated albumin (GA) were - 27.2 mg/dL, - 0.61%, and - 2.39%, respectively, in sitagliptin group, and 0.50 mg/dL, - 0.29%, and - 0.93%, respectively, in control group. The reductions in FPG, HbA1c, and GA were significantly greater in sitagliptin group (P < 0.0001, P < 0.01, and P < 0.0001, respectively). There were no differences in the incidence of adverse effects, except for cystatin C elevation and platelet count reduction in sitagliptin group. Sitagliptin treatment effectively improved the glycemic profile without any serious adverse effects in older T2D patients.Trial registration number: UMIN000010376.

Efficacy / safety balance of DPP-4 inhibitors versus SGLT2 inhibitors in elderly patients with type 2 diabetes

Dipeptidyl peptidase-4 inhibitors (DPP-4is) and sodium-glucose cotransporter type 2 inhibitors (SGLT2is) offer new options for the oral management of type 2 diabetes mellitus (T2DM), with the advantage in the elderly population to be devoid of a high risk of hypoglycaemia. SGLT2is have also shown benefits regarding cardiovascular (heart failure) and renal protection, including in patients with T2DM aged ≥ 65 years while DPP-4is have only proved cardiovascular and renal safety without superiority compared with placebo. The glucose-lowering efficacy of the two pharmacological classes is almost similar including in older patients with T2DM. However, the tolerance and safety profile may be highly different and overall more favourable with DPP-4is than with SGLT2is. Some adverse events have been reported with SGLT2is which may be more prevalent or severe in older patients than in younger patients. The present comprehensive review focuses on the benefit/risk balance in the elderly population with T2DM by comparing the profile of DPP-4is and SGLT2is regarding the following potential issues: metabolic disorders (hypoglycaemia and diabetic ketoacidosis); cardiac and vascular issues (atheromatous cardiovascular disease, heart failure, volume reduction hypotension, and lower limb amputations); renal endpoints including acute renal injury; risk of infections; digestive disorders; bone and skin adverse events; and cancer risk. Both DPP-4is and SGLT2is have their own advantages and disadvantages. Personalised treatment is recommended based upon the efficacy/safety profile of each drug class and individual patient characteristics that may be markedly different among the heterogeneous population of older individuals with T2DM.

Careful use to minimize adverse events of oral antidiabetic medications in the elderly

INTRODUCTION

An increasing number of older patients has type 2 diabetes treated with different oral antidiabetic agents whose safety may raise concern considering some particularities of a heterogeneous elderly population.

AREAS COVERED

This article discusses some characteristics of older patients that could increase the risk of adverse events, with a focus on hypoglycemia. It describes the most frequent and/or severe complications reported in the elderly in both randomized controlled trials and observational studies with metformin, sulfonylureas, meglitinides, alpha-glucosidase inhibitors, thiazolidinediones, dipeptidyl peptidase-4 inhibitors (gliptins) and sodium-glucose cotransporter type 2 inhibitors (gliflozins).

EXPERT OPINION

Old patients may present comorbidities (renal impairment, vascular disease, heart failure, risk of dehydration, osteoporosis, cognitive dysfunction) that could increase the risk of severe adverse events. Sulfonylureas (and meglitinides) induce hypoglycemia, which may be associated with falls/fractures and cardiovascular events. Medications lacking hypoglycemia should be preferred. Gliptins appear to have the best tolerance/safety profile whereas gliflozins exert a cardiorenal protection. However, data are lacking in very old or frailty old patients so that caution and appropriate supervision of such patients are required. Taking advantage of a large choice of pharmacotherapies, personalized treatment is recommended based upon both drug safety profiles and old patient individual characteristics.

Adverse Drug Events Associated with sitagliptin Versus canagliflozin for the Treatment of Patients with Type 2 Diabetes Mellitus: A Systematic Comparison Through a Meta-Analysis

INTRODUCTION

In this meta-analysis, we aimed to systematically compare the adverse drug events associated with sitagliptin (100 mg) versus canagliflozin 100 or 300 mg in patients who were treated for type 2 diabetes mellitus (T2DM).

METHODS

Online databases were searched for relevant studies comparing sitagliptin (100 mg) versus canagliflozin. Adverse drug events were considered as the clinical endpoints. The analysis was carried out by RevMan software whereby risk ratios (RR) and 95% confidence intervals (CI) were generated.

RESULTS

Five studies with a total number of 2322 patients were included. When sitagliptin (100 mg) was compared with canagliflozin (100 mg), the endpoints of any adverse events, adverse events leading to drug discontinuation, serious adverse events, urinary tract infections, hypoglycemia, and adverse events related to hypovolemia were not significantly different: (RR 1.10, 95% CI 1.00-1.21; P = 0.05), (RR 1.20, 95% CI 0.67-2.16; P = 0.54), (RR 0.90, 95% CI 0.49-1.66; P = 0.73), (RR 1.26, 95% CI 0.77-2.08; P = 0.36), (RR 1.01, 95% CI 0.30-3.43; P = 0.99), and (RR 1.76, 95% CI 0.52-5.94; P = 0.36), respectively. However, canagliflozin was associated with increased genital mycotic infection (RR 4.32, 95% CI 2.11-8.83; P = 0.0001). When genital mycotic infections associated with sitagliptin versus canagliflozin were compared in male and female patients separately, the risk was still significantly higher with canagliflozin: (RR 7.00, 95% CI 2.44-20.06; P = 0.003) and (RR 4.02, 95% CI 2.22-7.27; P = 0.00001), respectively. The same results were obtained when sitagliptin (100 mg) was compared to canagliflozin 300 mg.

CONCLUSIONS

Canagliflozin was associated with a significantly higher risk of genital mycotic infections when compared to sitagliptin. However, the other adverse drug events were similarly manifested when sitagliptin 100 mg was compared to either canagliflozin 100 or 300 mg.