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Weeda ER, Ward R, Gebregziabher M, Axon RN, Taber DJ. Impact of Race and Ethnicity on Severe Hypoglycemia Associated with Sulfonylurea Use for Type 2 Diabetes among Veterans. J Racial Ethn Health Disparities 2024; 11:1427-1433. [PMID: 37129787 PMCID: PMC10620099 DOI: 10.1007/s40615-023-01619-0] [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: 03/08/2023] [Revised: 04/22/2023] [Accepted: 04/25/2023] [Indexed: 05/03/2023]
Abstract
Sulfonylureas are associated with hypoglycemia. Whether a racial/ethnic disparity in this safety outcome exists is unknown. We sought to assess the impact of race/ethnicity on severe hypoglycemia associated with sulfonylurea use for type 2 diabetes (T2D). Using Veterans Affairs and Medicare data, Veterans initially receiving metformin monotherapy for T2D between 2004 and 2006 were identified. Sulfonylurea use (either alone or via the addition of a prescription for a sulfonylurea to metformin) was captured and compared to remaining on metformin alone during the follow-up period (2007-2016). Hazard ratios (HR) and 95% confidence intervals (CI) from longitudinal competing risk Cox models were used to measure the association between sulfonylurea use and severe hypoglycemia defined as hospitalization for hypoglycemia. A total of 113,668 Veterans with T2D were included. A higher risk of severe hypoglycemia was associated with the receipt of sulfonylurea prescriptions versus remaining on metformin alone across all groups. The effect was largest among Hispanic Veterans (HR: 7.59, 95%CI:4.32-13.33), followed by Veterans in the other race/ethnicity cohort (HR: 4.57, 95%CI:2.50-8.36) and Non-Hispanic Black Veterans (HR: 3.67, 95%CI:2.78-4.85). The effect was smallest among Non-Hispanic White Veterans (HR: 3.11, 95%CI:2.77-3.48). In conclusion, a higher risk of severe hypoglycemia associated with sulfonylurea prescriptions was observed across all analyses. The relationship was most pronounced for Hispanic Veterans, who had nearly 8 times the risk of severe hypoglycemia with sulfonylureas versus remaining on metformin alone.
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Affiliation(s)
- Erin R Weeda
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
- College of Pharmacy, Medical University of South Carolina, 280 Calhoun Street, Charleston, SC, 29425, USA.
| | - Ralph Ward
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
- Department of Public Health Science, Medical University of South Carolina, Charleston, SC, USA
| | - Mulugeta Gebregziabher
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
- Department of Public Health Science, Medical University of South Carolina, Charleston, SC, USA
| | - R Neal Axon
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - David J Taber
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
- Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
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Weeda ER, Ward R, Gebregziabher M, Chandler O, Strychalski ML, Axon RN, Taber DJ. Sulfonylureas as second line therapy for type 2 diabetes among veterans: Results from a National Longitudinal Cohort Study. Prim Care Diabetes 2023:S1751-9918(23)00089-X. [PMID: 37121788 DOI: 10.1016/j.pcd.2023.04.006] [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: 10/31/2022] [Revised: 04/18/2023] [Accepted: 04/26/2023] [Indexed: 05/02/2023]
Abstract
AIMS To assess if switching to or adding sulfonylureas increases major adverse cardiovascular events (MACE) or severe hypoglycemia versus remaining on metformin alone. MATERIALS AND METHODS This was a retrospective, longitudinal cohort utilizing United States Veterans Health Administration and Medicare data. Veterans with type 2 diabetes on metformin monotherapy between 2004 and 2006 were identified. Follow-up occurred through 2016. Those treated with either metformin plus a second-generation sulfonylurea (N = 45,305) or converted from metformin to a second-generation sulfonylurea (N = 2813) were compared to those receiving metformin monotherapy (N = 65,550). Hazard ratios (HR) and 95%CI from longitudinal competing risk Cox models were used to measure the association between sulfonylureas and outcomes. RESULTS Switching to or adding a sulfonylurea to metformin was associated with 3 times the risk of severe hypoglycemia versus metformin monotherapy (HR:3.44, 95% CI: 3.06,3.85 and HR: 3.08, 95% CI: 2.77,3.42, respectively). Switching to or adding a sulfonylurea to metformin was associated with a 7-19% higher risk of MACE versus metformin monotherapy (HR: 1.07, 95% CI: 1.00,1.14 and HR: 1.19, 95% CI: 1.13,1.25, respectively). CONCLUSIONS Switching to and adding second-generation sulfonylureas was associated an increase in severe hypoglycemia and MACE versus remaining on metformin alone. In an era where guidelines recommend diabetes therapies based on compelling indications, safety outcomes should be a key consideration when selecting therapy.
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Affiliation(s)
- Erin R Weeda
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA; College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Ralph Ward
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA; Department of Public Health Science, Medical University of South Carolina, Charleston, SC, USA
| | - Mulugeta Gebregziabher
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA; Department of Public Health Science, Medical University of South Carolina, Charleston, SC, USA
| | - Olivia Chandler
- Department of Pharmacy, Ralph H Johnson VAMC, Charleston, SC, USA
| | | | - R Neal Axon
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA; College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - David J Taber
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA; Department of Pharmacy, Ralph H Johnson VAMC, Charleston, SC, USA; Division of Transplant Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
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Xu Z, Zhang H, Wu C, Zheng Y, Jiang J. Effect of metformin on adverse outcomes in T2DM patients: Systemic review and meta-analysis of observational studies. Front Cardiovasc Med 2022; 9:944902. [PMID: 36211585 PMCID: PMC9539433 DOI: 10.3389/fcvm.2022.944902] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/08/2022] [Indexed: 11/15/2022] Open
Abstract
Background The cardiovascular protection effect of metformin on patients with type 2 diabetes mellitus (T2DM) remains inconclusive. This systemic review and meta-analysis were to estimate the effect of metformin on mortality and cardiovascular events among patients with T2DM. Methods A search of the Pubmed and EMBASE databases up to December 2021 was performed. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled by a random-effects model with an inverse variance method. Results A total of 39 studies involving 2473009 T2DM patients were adopted. Compared to non-metformin therapy, the use of metformin was not significantly associated with a reduced risk of major adverse cardiovascular event (MACE) (HR = 1.06, 95%CI 0.91–1.22; I2 = 82%), hospitalization (HR = 0.85, 95%CI 0.64–1.13; I2 = 98%), heart failure (HR = 0.86, 95%CI 0.60–1.25; I2 = 99%), stroke (HR = 1.16, 95%CI 0.88–1.53; I2 = 84%), and risk of AMI (HR = 0.88, 95%CI 0.69–1.14; I2 = 88%) in T2DM patients. Metformin was also not associated with significantly lowered risk of MACE compared to dipeptidyl peptidase-4 inhibitor (DPP-4i) in T2DM patients (HR = 0.95, 95%CI 0.73–1.23; I2 = 84%). Conclusions The effect of metformin on some cardiovascular outcomes was not significantly better than the non-metformin therapy or DPP-4i in T2DM patients based on observational studies.
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Affiliation(s)
- Zhicheng Xu
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
- *Correspondence: Zhicheng Xu
| | - Haidong Zhang
- Department of Nephrology, Peking University Third Hospital, Bejing, China
- Haidong Zhang
| | - Chenghui Wu
- School of Medicine, Sun Yat-sen University, Shenzhen, China
| | - Yuxiang Zheng
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingzhou Jiang
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Jingzhou Jiang
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Chow E, Yang A, Chung CHL, Chan JCN. A Clinical Perspective of the Multifaceted Mechanism of Metformin in Diabetes, Infections, Cognitive Dysfunction, and Cancer. Pharmaceuticals (Basel) 2022; 15:ph15040442. [PMID: 35455439 PMCID: PMC9030054 DOI: 10.3390/ph15040442] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 12/16/2022] Open
Abstract
In type 2 diabetes, ecological and lifecourse factors may interact with the host microbiota to influence expression of his/her genomes causing perturbation of interconnecting biological pathways with diverse clinical course. Metformin is a plant-based or plant-derived medicinal product used for the treatment of type 2 diabetes for over 60 years and is an essential drug listed by the World Health Organization. By reducing mitochondrial oxidative phosphorylation and adenosine triphosphate (ATP) production, metformin increased AMP (adenosine monophosphate)-activated protein kinase (AMPK) activity and altered cellular redox state with reduced glucagon activity, endogenous glucose production, lipogenesis, and protein synthesis. Metformin modulated immune response by directly reducing neutrophil to lymphocyte ratio and improving the phagocytic function of immune cells. By increasing the relative abundance of mucin-producing and short-chain-fatty-acid-producing gut microbes, metformin further improved the host inflammatory and metabolic milieu. Experimentally, metformin promoted apoptosis and reduced proliferation of cancer cells by reducing their oxygen consumption and modulating the microenvironment. Both clinical and mechanistic studies support the pluripotent effects of metformin on reducing cardiovascular–renal events, infection, cancer, cognitive dysfunction, and all-cause death in type 2 diabetes, making this low-cost medication a fundamental therapy for individualization of other glucose-lowering drugs in type 2 diabetes. Further research into the effects of metformin on cognitive function, infection and cancer, especially in people without diabetes, will provide new insights into the therapeutic value of metformin in our pursuit of prevention and treatment of ageing-related as well as acute and chronic diseases beyond diabetes.
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Affiliation(s)
- Elaine Chow
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong 999077, China; (E.C.); (A.Y.); (C.H.L.C.)
- The Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong 999077, China
- Phase 1 Clinical Trial Centre, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong 999077, China
| | - Aimin Yang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong 999077, China; (E.C.); (A.Y.); (C.H.L.C.)
- The Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong 999077, China
| | - Colin H. L. Chung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong 999077, China; (E.C.); (A.Y.); (C.H.L.C.)
| | - Juliana C. N. Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong 999077, China; (E.C.); (A.Y.); (C.H.L.C.)
- The Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong 999077, China
- Correspondence: ; Tel.: +852-3505-3138
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Ghallab DS, Shawky E, Metwally AM, Celik I, Ibrahim RS, Mohyeldin MM. Integrated in silico - in vitro strategy for the discovery of potential xanthine oxidase inhibitors from Egyptian propolis and their synergistic effect with allopurinol and febuxostat. RSC Adv 2022; 12:2843-2872. [PMID: 35425287 PMCID: PMC8979054 DOI: 10.1039/d1ra08011c] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/04/2022] [Indexed: 01/19/2023] Open
Abstract
Xanthine oxidase (XO) has been well-recognized as a validated target for the treatment of hyperuricemia and gout. Currently, there are two drugs in clinical use that shut down XO overactivity, allopurinol and febuxostat; however, detrimental side effects restrict their applications. Propolis is a unique natural adhesive biomass of structurally variable and biologically active metabolites that exert remarkable health benefits. Moreover, combination drug therapy has become a promising pharmacotherapeutic strategy directed for reformulating existing drugs into new combination entities with potentiating therapeutic impacts. In this study, computer-aided molecular docking and MD simulations accompanied by biochemical testing were used for mining novel pharmacologically active chemical entities from Egyptian propolis to combat hyperuricemia. Further, with a view to decrease the potential toxicity of synthetic drugs and enhance efficacy, propolis hits were subjected to combination analysis with each of allopurinol and febuxostat. More specifically, Glide docking was utilized for a structure-based virtual screening of in-house datasets comprising various Egyptian propolis metabolites. Rosmarinic acid, luteolin, techtochrysin and isoferulic acid were the most promising virtual hits. In vitro XO inhibitory assays demonstrated the ability of these hits to significantly inhibit XO in a dose-dependent manner. Molecular docking and MD simulations revealed a cooperative binding mode between the discovered hits and standard XO inhibitors within the active site. Subsequently, the most promising hits were tested in a fixed-ratio combination setting with allopurinol and febuxostat separately to assess their combined effects on XO catalytic inhibition. The binary combination of each techtochrysin and rosmarinic acid with febuxostat displayed maximal synergy at lower effect levels. In contrast, individually, techtochrysin and rosmarinic acid with allopurinol cooperated synergistically at high dose levels. Taken together, the suggested strategy seems imperative to ensure a steady supply of new therapeutic options sourced from Egyptian propolis to regress the development of hyperuricemia. Xanthine oxidase (XO) has been well-recognized as a validated target for the treatment of hyperuricemia and gout.![]()
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Affiliation(s)
- Dina S Ghallab
- Department of Pharmacognosy, Faculty of Pharmacy, Alexandria University Alexandria 21521 Egypt +20-1223821098
| | - Eman Shawky
- Department of Pharmacognosy, Faculty of Pharmacy, Alexandria University Alexandria 21521 Egypt +20-1223821098
| | - Ali M Metwally
- Department of Pharmacognosy, Faculty of Pharmacy, Alexandria University Alexandria 21521 Egypt +20-1223821098
| | - Ismail Celik
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Erciyes University Kayseri 38039 Turkey
| | - Reham S Ibrahim
- Department of Pharmacognosy, Faculty of Pharmacy, Alexandria University Alexandria 21521 Egypt +20-1223821098
| | - Mohamed M Mohyeldin
- Department of Pharmacognosy, Faculty of Pharmacy, Alexandria University Alexandria 21521 Egypt +20-1223821098
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Zhang K, Yang W, Dai H, Deng Z. Cardiovascular risk following metformin treatment in patients with type 2 diabetes mellitus: Results from meta-analysis. Diabetes Res Clin Pract 2020; 160:108001. [PMID: 31904444 DOI: 10.1016/j.diabres.2020.108001] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/17/2019] [Accepted: 12/31/2019] [Indexed: 12/16/2022]
Abstract
AIM Pharmacologic therapy for T2DM has proven benefits in terms of reducing elevated blood glucose levels and reducing microvascular complications. However, the impact of metformin on adverse cardiovascular outcomes and cardiovascular mortality is less clear. We carried out this meta-analysis on all published studies to estimate the overall cardiovascular risk following metformin treatment in patients with T2DM. METHODS We searched the PubMed, Embase and CNKI (China National Knowledge Infrastructure) databases for all articles. The odds ratio (OR) corresponding to the 95% confidence interval (95% CI) was used to assess the cardiovascular risk following metformin treatment in patients with T2DM. The statistical heterogeneity among studies was assessed with the Q-test and I2 statistics. RESULTS We collected 16 studies including 25 comparisons with 1,160,254 patients of type 2 diabetes mellitus and 701,843 patients of T2DM following metformin treatment. Our results found statistical evidence of significantly decreased cardiovascular risk to be associated with following treatment with metformin in patients with type 2 diabetes mellitus (OR = 0.57, 95% CI = 0.48-0.68) (shown in Table 1 and Fig. 2), both with the mortality (OR = 0.44, 95% CI = 0.34-0.57) and incidence (OR = 0.73, 95% CI = 0.59-0.90). CONCLUSIONS Our meta-analysis indicated that following metformin treatment in patients with T2DM was associated with decreased cardiovascular risk, both with the mortality and incidence. However, the heterogeneity among studies may potentially affect the final results.
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Affiliation(s)
- Kui Zhang
- Department of Forensic Pathology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan 610041, People's Republic of China
| | - Wenxing Yang
- Department of Physiology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan 610041, People's Republic of China
| | - Hao Dai
- Department of Forensic Pathology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan 610041, People's Republic of China
| | - Zhenhua Deng
- Department of Forensic Pathology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan 610041, People's Republic of China.
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Han Y, Xie H, Liu Y, Gao P, Yang X, Shen Z. Effect of metformin on all-cause and cardiovascular mortality in patients with coronary artery diseases: a systematic review and an updated meta-analysis. Cardiovasc Diabetol 2019; 18:96. [PMID: 31362743 PMCID: PMC6668189 DOI: 10.1186/s12933-019-0900-7] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/22/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Metformin is the most widely prescribed drug to lower glucose and has a definitive effect on the cardiovascular system. The goal of this systematic review and meta-analysis is to assess the effects of metformin on mortality and cardiac function among patients with coronary artery disease (CAD). METHODS Relevant studies reported before October 2018 was retrieved from databases including PubMed, EMBASE, Cochrane Library and Web of Science. Hazard ratio (HR) was calculated to evaluate the all-cause mortality, cardiovascular mortality and incidence of cardiovascular events (CV events), to figure out the level of left ventricular ejection fraction (LVEF), creatine kinase MB (CK-MB), type B natriuretic peptide (BNP) and to compare the average level of low density lipoprotein (LDL). RESULTS In this meta-analysis were included 40 studies comprising 1,066,408 patients. The cardiovascular mortality, all-cause mortality and incidence of CV events were lowered to adjusted HR (aHR) = 0.81, aHR = 0.67 and aHR = 0. 83 respectively after the patients with CAD were given metformin. Subgroup analysis showed that metformin reduced all-cause mortality in myocardial infarction (MI) (aHR = 0.79) and heart failure (HF) patients (aHR = 0.84), the incidence of CV events in HF (aHR = 0.83) and type II diabetes mellitus (T2DM) patients (aHR = 0.83), but had no significant effect on MI (aHR = 0.87) and non-T2DM patients (aHR = 0.92). Metformin is superior to sulphonylurea (aHR = 0.81) in effects on lowering the incidence of CV events and in effects on patients who don't use medication. The CK-MB level in the metformin group was lower than that in the control group standard mean difference (SMD) = - 0.11). There was no significant evidence that metformin altered LVEF (MD = 2.91), BNP (MD = - 0.02) and LDL (MD = - 0.08). CONCLUSION Metformin reduces cardiovascular mortality, all-cause mortality and CV events in CAD patients. For MI patients and CAD patients without T2DM, metformin has no significant effect of reducing the incidence of CV events. Metformin has a better effect of reducing the incidence of CV events than sulfonylureas.
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Affiliation(s)
- Yechen Han
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Hongzhi Xie
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Yongtai Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Peng Gao
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Xufei Yang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Zhujun Shen
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
- Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China.
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Davis TME, Bruce DG, Finn J, Curtis BH, Barraclough H, Davis WA. Temporal changes in the incidence and predictors of severe hypoglycaemia in type 2 diabetes: The Fremantle Diabetes Study. Diabetes Obes Metab 2019; 21:648-657. [PMID: 30370611 DOI: 10.1111/dom.13568] [Citation(s) in RCA: 5] [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: 09/02/2018] [Revised: 10/22/2018] [Accepted: 10/25/2018] [Indexed: 12/12/2022]
Abstract
AIM To determine the incidence of severe hypoglycaemia and its predictors in community-based patients with type 2 diabetes studied between 2008 and 2013 compared with those in a cohort of patients with type 2 diabetes from the same geographical area assessed a decade earlier. METHODS We studied 1551 participants (mean age 65.7 years, 51.9% men) with type 2 diabetes from the longitudinal observational Fremantle Diabetes Study Phase II (FDS2). Severe hypoglycaemia was ascertained as that requiring ambulance attendance, emergency department services and/or hospitalization. Cox proportional hazards modelling was used to determine predictors of a first episode of severe hypoglycaemia, and negative binomial regression was used to identify predictors of frequency. RESULTS Sixty-three participants (4.1%) experienced 83 episodes, representing an incidence of 1.34/100 participant-years (95% confidence interval [CI] 1.08 to 1.67; vs 1.67/100 participant-years [95% CI 1.31-2.13] in the Fremantle Diabetes Study Phase I [FDS1]; P = 0.18). Those experiencing severe hypoglycaemia experienced one to four episodes in both cohorts. The independent predictors of incident severe hypoglycaemia in the FDS2 were: older age; higher educational attainment; alcohol consumption; current smoking; sulphonylurea/insulin treatment; prior severe hypoglycaemia; renal impairment; and plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP). The same variables except smoking were associated with frequency of severe hypoglycaemia. Most of these risk factors paralleled those in the FDS1, but current smoking and plasma NT-proBNP were novel. CONCLUSIONS The incidence and frequency of severe hypoglycaemia did not change between the Fremantle Diabetes Study phases but novel risk factors, including plasma NT-proBNP, were observed in the FDS2.
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Affiliation(s)
- Timothy M E Davis
- Medical School, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - David G Bruce
- Medical School, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Judith Finn
- School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, Western Australia, Australia
| | - Bradley H Curtis
- Eli Lilly Australia and New Zealand, West Ryde, New South Wales, Australia
| | - Helen Barraclough
- Eli Lilly Australia and New Zealand, West Ryde, New South Wales, Australia
| | - Wendy A Davis
- Medical School, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
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Carbone S, Dixon DL, Buckley LF, Abbate A. Glucose-Lowering Therapies for Cardiovascular Risk Reduction in Type 2 Diabetes Mellitus: State-of-the-Art Review. Mayo Clin Proc 2018; 93:1629-1647. [PMID: 30392544 PMCID: PMC6501786 DOI: 10.1016/j.mayocp.2018.07.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/18/2018] [Accepted: 07/17/2018] [Indexed: 02/07/2023]
Abstract
Type 2 diabetes mellitus (T2DM) is a major cardiovascular (CV) risk factor. Although antihyperglycemic therapies have typically focused on glycemic control, a paradigm shift for the treatment of T2DM has occurred, with an increased focus on CV risk reduction. Clinicians should base their clinical decisions on the beneficial effects of specific glucose-lowering agents on CV outcomes, while avoiding those therapeutic strategies with potential detrimental effects. Importantly, the presence of comorbidities (eg, established cardiovascular diseases, hypertension, obesity) should also guide the clinical decision toward therapies proven to reduce CV outcomes in that specific population. In this state-of-the-art review resulting from a comprehensive literature search (Pubmed, Google Scholar), we summarize the evidence related to the CV outcomes trials reported in the past several decades. Finally, we propose a therapeutic plan for patients with T2DM, suggesting the use of specific glucose-lowering agents based on the characteristics and presence of comorbidities of the individual patient.
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Affiliation(s)
- Salvatore Carbone
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA.
| | - Dave L Dixon
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA
| | - Leo F Buckley
- Division of Cardiovascular Medicine and Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
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Douros A, Dell'Aniello S, Yu OHY, Filion KB, Azoulay L, Suissa S. Sulfonylureas as second line drugs in type 2 diabetes and the risk of cardiovascular and hypoglycaemic events: population based cohort study. BMJ 2018; 362:k2693. [PMID: 30021781 PMCID: PMC6050517 DOI: 10.1136/bmj.k2693] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess whether adding or switching to sulfonylureas is associated with an increased risk of myocardial infarction, ischaemic stroke, cardiovascular death, all cause mortality, and severe hypoglycaemia, compared with remaining on metformin monotherapy in patients with type 2 diabetes. DESIGN Population based cohort study. SETTING General practices contributing data to the UK Clinical Practice Research Datalink. PARTICIPANTS Patients with type 2 diabetes initiating metformin monotherapy between 1998 and 2013. MAIN OUTCOME MEASURES Using the prevalent new-user cohort design we matched 1:1 patients adding or switching to sulfonylureas with those remaining on metformin monotherapy on high-dimensional propensity score, haemoglobin A1c, and number of previous metformin prescriptions. The two groups were compared using Cox proportional hazards models to estimate adjusted hazard ratios and 95% confidence intervals for the study outcomes. RESULTS Among 77 138 metformin initiators, 25 699 added or switched to sulfonylureas during the study period. During a mean follow-up of 1.1 years, sulfonylureas were associated with an increased risk of myocardial infarction (incidence rate 7.8 v 6.2 per 1000 person years, hazard ratio 1.26, 95% confidence interval 1.01 to 1.56), all cause mortality (27.3 v 21.5, 1.28, 1.15 to 1.44), and severe hypoglycaemia (5.5 v 0.7, 7.60, 4.64 to 12.44) compared with continuing metformin monotherapy. There was a trend towards increased risks of ischaemic stroke (6.7 v 5.5, 1.24, 0.99 to 1.56) and cardiovascular death (9.4 v 8.1, 1.18, 0.98 to 1.43). Compared with adding sulfonylureas, switching to sulfonylureas was associated with an increased risk of myocardial infarction (hazard ratio 1.51, 95% confidence interval, 1.03 to 2.24) and all-cause mortality (1.23, 1.00 to 1.50). No differences were observed for ischaemic stroke, cardiovascular death, or severe hypoglycaemia. CONCLUSIONS Sulfonylureas as second line drugs are associated with an increased risk of myocardial infarction, all cause mortality, and severe hypoglycaemia, compared with remaining on metformin monotherapy. Continuing metformin when introducing sulfonylureas appears to be safer than switching.
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Affiliation(s)
- Antonios Douros
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, H-461 Montréal, QC H3T 1E2, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, QC, Canada
- Institute of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sophie Dell'Aniello
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, H-461 Montréal, QC H3T 1E2, Canada
| | - Oriana Hoi Yun Yu
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, H-461 Montréal, QC H3T 1E2, Canada
- Division of Endocrinology, Jewish General Hospital, Montréal, QC, Canada
| | - Kristian B Filion
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, H-461 Montréal, QC H3T 1E2, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, QC, Canada
- Division of Clinical Epidemiology, Department of Medicine, McGill University, Montréal, QC, Canada
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, H-461 Montréal, QC H3T 1E2, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, QC, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montréal, QC, Canada
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, H-461 Montréal, QC H3T 1E2, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, QC, Canada
- Division of Clinical Epidemiology, Department of Medicine, McGill University, Montréal, QC, Canada
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11
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Anagnostis P, Siolos P, Christou K, Gkekas NK, Kosmidou N, Athyros VG, Karagiannis A. The effect of antidiabetic medications on the cardiovascular system: a critical appraisal of current data. Hormones (Athens) 2018; 17:83-95. [PMID: 29858866 DOI: 10.1007/s42000-018-0017-5] [Citation(s) in RCA: 2] [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] [Received: 10/27/2017] [Accepted: 01/23/2018] [Indexed: 02/07/2023]
Abstract
Both type 1 and type 2 diabetes are associated with increased risk for cardiovascular disease (CVD) events. This risk seems to be reduced by achievement of euglycemia. However, after the withdrawal of rosiglitazone from the market, the question arose as to whether this risk concerns simply a matter of euglycemia or the distinct role played by each antidiabetic drug with respect to its effect on CVD risk. To address this issue, many studies have been published during the last decade involving old and new antidiabetic agents, which however yielded contradictory results. Briefly, metformin is still considered safe and confers a beneficial effect on CVD risk. Conflicting data exist as concerns sulfonylureas, although the second and third generation representatives are regarded as relatively safe. Pioglitazone use seems to be associated with a reduction in CVD risk, whereas the dipeptidyl-dipeptidase-4 inhibitors (DPP-4i), lixisenatide and exenatide-LAR [from the category of glucagon-like-peptide-1 receptor (GLP-1R) agonists], confer a neutral effect. Two other GLP-1R agonists, liraglutide and semaglutide, as well as the sodium-glucose transporter-2 (SGLT2)-inhibitors, empagliflozin and cangliflozin, have shown an additional effect on CVD risk reduction, although their safety is in doubt. Insulin analogues and newer long-acting compounds are also safe for the cadiovascular system. The aim of this narrative review is to present and critically analyse the current data for each antidiabetic drug category with regard to their effect on CVD risk.
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Affiliation(s)
- Panagiotis Anagnostis
- Police Medical Center of Thessaloniki, Thessaloniki, Greece.
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, Sarantaporou 10, 546 40, Thessaloniki, Greece.
| | - Pavlos Siolos
- Police Medical Center of Thessaloniki, Thessaloniki, Greece
| | | | - Nifon K Gkekas
- Police Medical Center of Thessaloniki, Thessaloniki, Greece
| | | | - Vasilios G Athyros
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, Sarantaporou 10, 546 40, Thessaloniki, Greece
| | - Asterios Karagiannis
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, Sarantaporou 10, 546 40, Thessaloniki, Greece
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12
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Davis TME, Chubb SAP, Bruce DG, Davis WA. Metabolic memory and all-cause death in community-based patients with type 2 diabetes: the Fremantle Diabetes Study. Diabetes Obes Metab 2016; 18:598-606. [PMID: 26936654 DOI: 10.1111/dom.12655] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/12/2016] [Accepted: 02/28/2016] [Indexed: 12/18/2022]
Abstract
AIMS To validate the findings, in a usual care setting, of glycaemic intervention trials, which have shown that tight control in patients with recently diagnosed type 2 diabetes protects against death during post-study monitoring, but that it may be deleterious in long-duration diabetes with vascular complications. METHODS A subset of 531 patients with type 2 diabetes from the community-based observational Fremantle Diabetes Study Phase 1, who attended ≥5 annual reviews (mean follow-up 15.9 years), were categorized by baseline diabetes duration [<1 year (Group 1); 1 to <5 years (Group 2); and ≥5 years (Group 3)]. Glycated haemoglobin (HbA1c) trajectories over the first 5 years were determined [low, medium and high; equivalent to mean HbA1c ≤6.6% (<49 mmol/mol), 6.7-8.0% (50-64 mmol/mol) and ≥8.0% (>64 mmol/mol), respectively]. Kaplan-Meier analysis was used to assess survival by duration and HbA1c trajectory. Cox proportional hazards modelling identified predictors of all-cause death. RESULTS There was greater mortality in patients with a medium versus those with a low trajectory in Group 1: hazard ratio (HR) 1.99 [95% confidence interval (CI) 1.003-3.94; p = 0.049], and in patients with a high versus a low trajectory in Group 2: HR 2.02 (95% CI 1.11-3.71; p = 0.022). In Group 3, both medium [HR 0.57 (95% CI 0.35-0.92; p = 0.022)] and high [HR 0.56 (95% CI 0.32-0.96); p = 0.035] trajectories were independently and inversely associated with death. CONCLUSIONS In community-based patients with newly or recently diagnosed type 2 diabetes, poor glycaemic control was an adverse prognostic indicator. Tight control was independently associated with death in patients with diabetes duration ≥5 years. These data parallel intervention trial findings and support individualization of HbA1c targets.
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Affiliation(s)
- T M E Davis
- School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - S A P Chubb
- School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Western Australia, Australia
- Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital, Perth, Western Australia, Australia
- School of Pathology and Laboratory Medicine, University of Western Australia, Nedlands, Western Australia, Australia
- Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - D G Bruce
- School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - W A Davis
- School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Western Australia, Australia
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13
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Abstract
Sulfonylureas (SUs) remain the most commonly prescribed drug after metformin in the treatment of type 2 diabetes (T2DM), despite the availability of several newer agents. The primary reason of SUs being most popular is their quick glycemic response, time-tested experience and least cost. Although SUs are one amongst the several other second line agents after metformin in all major guidelines, the new Dutch type 2 guidelines specifically advise gliclazide as the preferred second line drug instead of SUs as a class. The World Health Organization (WHO) has also included gliclazide in their Model List of Essential Medicines 2013 motivated by its safety data in elderly patients. Specifically advising gliclazide may have been based on emerging evidence suggesting cardiovascular neutrality of gliclazide over other SUs. This prompted us to do a literature review of gliclazide efficacy and safety data compared to other SUs as well as oral anti-diabetic drugs.
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Affiliation(s)
| | - Ritu Singh
- a G.D Hospital & Diabetes Institute , Kolkata , West Bengal , India
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14
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Ferrannini E, DeFronzo RA. Impact of glucose-lowering drugs on cardiovascular disease in type 2 diabetes. Eur Heart J 2015; 36:2288-96. [PMID: 26063450 DOI: 10.1093/eurheartj/ehv239] [Citation(s) in RCA: 182] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 05/16/2015] [Indexed: 12/11/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is characterized by multiple pathophysiologic abnormalities. With time, multiple glucose-lowering medications are commonly required to reduce and maintain plasma glucose concentrations within the normal range. Type 2 diabetes mellitus individuals also are at a very high risk for microvascular complications and the incidence of heart attack and stroke is increased two- to three-fold compared with non-diabetic individuals. Therefore, when selecting medications to normalize glucose levels in T2DM patients, it is important that the agent not aggravate, and ideally even improve, cardiovascular risk factors (CVRFs) and reduce cardiovascular morbidity and mortality. In this review, we examine the effect of oral (metformin, sulfonylureas, meglitinides, thiazolidinediones, DPP4 inhibitors, SGLT2 inhibitors, and α-glucosidase inhibitors) and injectable (glucagon-like peptide-1 receptor agonists and insulin) glucose-lowering drugs on established CVRFs and long-term studies of cardiovascular outcomes. Firm evidence that in T2DM cardiovascular disease can be reversed or prevented by improving glycaemic control is still incomplete and must await large, long-term clinical trials in patients at low risk using modern treatment strategies, i.e., drug combinations designed to maximize HbA1c reduction while minimizing hypoglycaemia and excessive weight gain.
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Affiliation(s)
- Ele Ferrannini
- Institute of Clinical Physiology, National Research Council (CNR), Pisa, Italy
| | - Ralph A DeFronzo
- Diabetes Division, University of Texas Health Science Center, San Antonio, TX, USA
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15
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Patorno E, Garry EM, Patrick AR, Schneeweiss S, Gillet VG, Zorina O, Bartels DB, Seeger JD. Addressing Limitations in Observational Studies of the Association Between Glucose-Lowering Medications and All-Cause Mortality: A Review. Drug Saf 2015; 38:295-310. [DOI: 10.1007/s40264-015-0280-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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16
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Simpson SH, Lee J, Choi S, Vandermeer B, Abdelmoneim AS, Featherstone TR. Mortality risk among sulfonylureas: a systematic review and network meta-analysis. Lancet Diabetes Endocrinol 2015; 3:43-51. [PMID: 25466239 DOI: 10.1016/s2213-8587(14)70213-x] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sulfonylureas are common second-line options for management of type 2 diabetes; however, they are associated with a higher risk of cardiovascular events compared with other antidiabetic drugs. Since tissue selectivity and risk of hypoglycaemia differ among sulfonylureas, we aimed to assess whether mortality and the risk of cardiovascular events also varies. METHODS We searched Medline and Embase from inception to June 11, 2014, to identify controlled studies reporting the risk of all-cause mortality, cardiovascular-related mortality, or myocardial infarction for at least two sulfonylureas. We examined differences in cardiovascular event risk among sulfonylureas with random effects models for direct pairwise comparisons and network meta-analyses to incorporate direct and indirect data. FINDINGS 14 970 (9%) of 167 327 patients in 18 studies died: 841 (4%) of 19 334 gliclazide users, 5482 (11%) of 49 389 glimepiride users, 2106 (15%) of 14 464 glipizide users, 5296 (7%) of 77 169 glibenclamide users, 1066 (17%) of 6187 tolbutamide users, and 179 (23%) of 784 chlorpropamide users. Inconsistency was low for the network meta-analysis of all-cause mortality, and the relative risk of death compared with glibenclamide was 0·65 (95% credible interval 0·53-0·79) for gliclazide, 0·83 (0·68-1·00) for glimepiride, 0·98 (0·80-1·19) for glipizide, 1·13 (0·90-1·42) for tolbutamide, and 1·34 (0·98-1·86) for chlorpropamide. Similar associations were noted for cardiovascular-related mortality: the relative risk compared with glibenclamide was 0·60 (95% credible interval 0·45-0·84) for gliclazide, 0·79 (0·57-1·11) for glimepiride, 1·01 (0·72-1·43) for glipizide, 1·11 (0·79-1·55) for tolbutamide, and 1·45 (0·88-2·44) for chlorpropamide. INTERPRETATION Gliclazide and glimepiride were associated with a lower risk of all-cause and cardiovascular-related mortality compared with glibenclamide. Clinicians should consider possible differences in risk of mortality when selecting a sulfonylurea. FUNDING None.
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Affiliation(s)
- Scot H Simpson
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada.
| | - Jayson Lee
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Sabina Choi
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ahmed S Abdelmoneim
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Travis R Featherstone
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
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17
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Patorno E, Patrick AR, Garry EM, Schneeweiss S, Gillet VG, Bartels DB, Masso-Gonzalez E, Seeger JD. Observational studies of the association between glucose-lowering medications and cardiovascular outcomes: addressing methodological limitations. Diabetologia 2014; 57:2237-50. [PMID: 25212258 DOI: 10.1007/s00125-014-3364-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 08/06/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recent years have witnessed a growing body of observational literature on the association between glucose-lowering treatments and cardiovascular disease. However, many of the studies are based on designs or analyses that inadequately address the methodological challenges involved. METHODS We reviewed recent observational literature on the association between glucose-lowering medications and cardiovascular outcomes and assessed the design and analysis methods used, with a focus on their ability to address specific methodological challenges. We describe and illustrate these methodological issues and their impact on observed associations, providing examples from the reviewed literature. We suggest approaches that may be employed to manage these methodological challenges. RESULTS From the evaluation of 81 publications of observational investigations assessing the association between glucose-lowering treatments and cardiovascular outcomes, we identified the following methodological challenges: 1) handling of temporality in administrative databases; 2) handling of risks that vary with time and treatment duration; 3) definitions of the exposure risk window; 4) handling of exposures that change over time; and 5) handling of confounding by indication. Most of these methodological challenges may be suitably addressed through application of appropriate methods. CONCLUSIONS/INTERPRETATION Observational research plays an increasingly important role in the evaluation of the clinical effects of diabetes treatment. Implementation of appropriate research methods holds the promise of reducing the potential for spurious findings and the risk that the spurious findings will mislead the medical community about risks and benefits of diabetes medications.
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Affiliation(s)
- Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street (Suite 3030), Boston, MA, 02120, USA,
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18
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Masmiquel L. [Cardiovascular effects and safety of glucose-lowering drugs: current situation]. Semergen 2014; 40:80-8. [PMID: 24655910 DOI: 10.1016/j.semerg.2012.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 11/23/2012] [Accepted: 12/01/2012] [Indexed: 10/27/2022]
Abstract
Diabetes mellitus is an independent cardiovascular risk factor. Therefore, in addition to normalising blood glucose, the aim of the treatment for diabetes mellitus should be to prevent cardiovascular complications. However, the evidence available on the cardio-protective role of the different glucose-lowering drugs is scarce and poor, particularly as regards with the risk of major cardiovascular events. In this context, the regulatory agencies have modified the regulations for the approval of glucose-lowering drugs, now requiring to demonstrate the glucose-lowering effect together with a robust assessment of the cardiovascular safety. The aim of this work is to review the cardiovascular effects of the different glucose-lowering drugs, focusing on their impact on the risk of major cardiovascular events.
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Affiliation(s)
- L Masmiquel
- Servicio de Endocrinología, Hospital Son Llàtzer, Palma de Mallorca, España.
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19
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Szuszkiewicz-Garcia MM, Davidson JA. Cardiovascular disease in diabetes mellitus: risk factors and medical therapy. Endocrinol Metab Clin North Am 2014; 43:25-40. [PMID: 24582090 DOI: 10.1016/j.ecl.2013.09.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Cardiovascular disease is a serious complication of diabetes mellitus. In the last 2 decades, great strides have been made in reducing microvascular complications in patients with diabetes through improving glycemic control. Decreasing rates of cardiovascular events have proved to be more difficult than simply intensifying the management of hyperglycemia. A tremendous effort has been made to deepen understanding of cardiovascular disease in diabetes and to formulate the best treatment approach. This review summarizes the current state of knowledge and discusses areas of uncertainty in the care of patients with diabetes who are at risk for cardiovascular disease.
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Affiliation(s)
- Magdalene M Szuszkiewicz-Garcia
- Division of Endocrinology and Metabolism, Center for Human Nutrition, Department of Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8857, USA.
| | - Jaime A Davidson
- Division of Endocrinology, Diabetes and Metabolism, Touchstone Diabetes Center, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard K5.246, Dallas, TX 75390, USA
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20
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Weidman-Evans E, Metz SM, Evans JD. Cardiovascular risks and benefits with oral drugs for Type 2 diabetes mellitus. Expert Rev Clin Pharmacol 2014; 7:225-33. [PMID: 24490745 DOI: 10.1586/17512433.2014.885836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Type 2 diabetes mellitus affects approximately 321 million people worldwide. It is estimated that about half of these patients will die from cardiovascular complications. In spite of these statistics, medications for diabetes are approved based not on outcomes, but on surrogate markers such as blood glucose or glycosylated hemoglobin. In recent years, however, the safety of diabetes medications has come under scrutiny, and more studies are being undertaken to determine the effect(s) of the medications on actual outcomes. In this review the authors review available study results for all of the currently approved classes of oral medications for Type 2 diabetes, and discuss the possible mechanisms for the findings. More studies are necessary for many of these classes, however, to make definitive recommendations regarding their cardiovascular effects.
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Affiliation(s)
- Emily Weidman-Evans
- Department of Clinical and Administrative Sciences, University of Louisiana at Monroe College of Pharmacy, Louisiana 71201, LA, USA
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Ghotbi AA, Køber L, Finer N, James WPT, Sharma AM, Caterson I, Coutinho W, Van Gaal LF, Torp-Pedersen C, Andersson C. Association of hypoglycemic treatment regimens with cardiovascular outcomes in overweight and obese subjects with type 2 diabetes: a substudy of the SCOUT trial. Diabetes Care 2013; 36:3746-53. [PMID: 24089540 PMCID: PMC3816850 DOI: 10.2337/dc13-0027] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the association of hypoglycemic treatment regimens with cardiovascular adverse events and mortality in a large population of type 2 diabetic patients at increased cardiovascular risk. RESEARCH DESIGN AND METHODS This analysis included 8,192 overweight patients with type 2 diabetes from the Sibutramine Cardiovascular Outcomes (SCOUT) trial randomized to lifestyle intervention with or without sibutramine for up to 6 years. Patients were grouped according to hypoglycemic treatment at baseline. The primary end point was the time from randomization to the first occurrence of a primary outcome event (POE), nonfatal myocardial infarction, nonfatal stroke, resuscitation after cardiac arrest, or cardiovascular death. Multivariable Cox proportional hazards regression models were used to assess the impact of antiglycemic treatment on POE and all-cause mortality. RESULTS Treatments for type 2 diabetes were as follows: diet alone (n = 1,394 subjects), metformin monotherapy (n = 1,631), insulin monotherapy (n = 1,116), sulfonylurea monotherapy (n = 1,083), metformin plus sulfonylurea (n = 1,565), and metformin plus insulin (n = 1,000); 905 subjects experienced a POE and 708 died. Metformin monotherapy was associated with lower risk of POE than insulin (hazard ratio [HR], 0.74; 95% CI, 0.57-0.95; P = 0.02). Diet alone also was associated with lower risk of POE (HR, 0.65; 95% CI, 0.48-0.87; P = 0.004). Metformin monotherapy also was associated with lower mortality (HR, 0.73; 95% CI, 0.54-0.99; P < 0.05), whereas no other monotherapies or combination therapies were significantly associated with POE or all-cause mortality compared with insulin as monotherapy. CONCLUSIONS In obese patients with type 2 diabetes and high risk of cardiovascular disease, monotherapy with metformin or diet-only treatment was associated with lower risk of cardiovascular events than treatment with insulin.
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Phung OJ, Schwartzman E, Allen RW, Engel SS, Rajpathak SN. Sulphonylureas and risk of cardiovascular disease: systematic review and meta-analysis. Diabet Med 2013; 30:1160-71. [PMID: 23663156 DOI: 10.1111/dme.12232] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2013] [Indexed: 12/13/2022]
Abstract
AIMS Sulphonylurea use has been linked with increased cardiovascular disease risk; however, previous studies have been inconsistent. Type 2 diabetes independently increases risk for cardiovascular disease, so understanding the link between longer-term use of anti-diabetic medications and cardiovascular disease has important clinical implications. METHODS Literature search in MEDLINE and CENTRAL was conducted throughout December 2011 for clinical and observational studies that reported the association between sulphonylurea and cardiovascular disease events. Ratios (relative risk, odds ratios or hazard ratios) adjusted for potential confounders (concomitant medications, baseline cardiovascular risk, diabetes severity) were pooled using a random-effects model to yield relative risks and associated 95% confidence intervals. RESULTS This meta-analysis included 33 studies (n = 1,325,446 patients), followed for a range of 0.46-10.4 years. In all studies, compared with other oral diabetes drugs, sulphonylurea use was associated with a significantly increased risk of cardiovascular death (relative risk 1.27, 95% confidence interval 1.18-1.34, n = 27 comparisons) and composite cardiovascular event (including myocardial infarction, stroke, cardiovascular-related hospitalization or cardiovascular death) (relative risk 1.10, 95% confidence interval 1.04-1.16, n = 43 comparisons). In studies comparing sulphonylurea vs. metformin, these relative risks were 1.26 (95% confidence interval 1.17-1.35, n = 17 comparisons) and 1.18 (95%confidence interval 1.13-1.24, n = 16 comparisons), respectively. CONCLUSIONS Results suggest that sulphonylurea use may elevate the risk of cardiovascular disease among patients with diabetes. This meta-analysis expands the pool of studies evaluating cardiovascular mortality compared with prior observations while using adjusted estimates, and assessing an additional outcome of a composite cardiovascular event. This finding warrants consideration in clinical practice when other treatment options may be available.
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Affiliation(s)
- O J Phung
- Western University of Health Sciences, College of Pharmacy, Pomona; Western Diabetes Institute, Pomona, CA
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The relationship between hypomagnesemia, metformin therapy and cardiovascular disease complicating type 2 diabetes: the Fremantle Diabetes Study. PLoS One 2013; 8:e74355. [PMID: 24019966 PMCID: PMC3760872 DOI: 10.1371/journal.pone.0074355] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 08/02/2013] [Indexed: 12/15/2022] Open
Abstract
Background Low serum magnesium concentrations have been associated with cardiovascular disease risk and outcomes in some general population studies but there are no equivalent studies in diabetes. Metformin may have cardiovascular benefits beyond blood glucose lowering in type 2 diabetes but its association with hypomagnesemia appears paradoxical. The aim of this study was to examine relationships between metformin therapy, magnesium homoeostasis and cardiovascular disease in well-characterized type 2 patients from the community. Methods and Findings We studied 940 non-insulin-treated patients (mean±SD age 63.4±11.6 years, 49.0% males) from the longitudinal observational Fremantle Diabetes Study Phase I (FDS1) who were followed for 12.3±5.3 years. Baseline serum magnesium was measured using stored sera. Multivariate methods were used to determine associates of prevalent and incident coronary heart disease (CHD) and cerebrovascular disease (CVD) as ascertained from self-report and linked morbidity/mortality databases. 19% of patients were hypomagnesemic (serum magnesium <0.70 mmol/L). Patients on metformin, alone or combined with a sulfonylurea, had lower serum magnesium concentrations than those on diet alone (P<0.05). There were no independent associations between serum magnesium or metformin therapy and either CHD or CVD at baseline. Incident CVD, but not CHD, was independently and inversely associated with serum magnesium (hazard ratio (95% CI) 0.28 (0.11–0.74); P = 0.010), but metformin therapy was not a significant variable in these models. Conclusions Since hypomagnesemia appears to be an independent risk factor for CVD complicating type 2 diabetes, the value of replacement therapy should be investigated further, especially in patients at high CVD risk.
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DeFronzo RA, Eldor R, Abdul-Ghani M. Pathophysiologic approach to therapy in patients with newly diagnosed type 2 diabetes. Diabetes Care 2013; 36 Suppl 2:S127-38. [PMID: 23882037 PMCID: PMC3920797 DOI: 10.2337/dcs13-2011] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Ralph A DeFronzo
- Diabetes Division, University of Texas Health Science Center, San Antonio, Texas, USA.
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Bo S, Castiglione A, Ghigo E, Gentile L, Durazzo M, Cavallo-Perin P, Ciccone G. Mortality outcomes of different sulphonylurea drugs: the results of a 14-year cohort study of type 2 diabetic patients. Eur J Endocrinol 2013; 169:117-26. [PMID: 23660643 DOI: 10.1530/eje-13-0299] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Available data about mortality of type 2 diabetic patients treated with different sulphonylureas are scarce and contradictory. DESIGN We evaluated the associations between all-cause and cause-specific mortality and treatments with different sulphonylureas in a retrospective cohort of type 2 diabetic patients from a diabetes clinic. METHODS All 1277 patients treated with sulphonylureas during 19961997 were enrolled: 159 patients were treated with tolbutamide, 977 glibenclamide and 141 gliclazide. The baseline data (centralised laboratory parameters, anthropometric data and presence of chronic complications) were abstracted from the clinical records. Information on vital status was collected from demographic files after 14-year follow-up. Adjusted hazard ratios (HR) were estimated with Cox (all-cause mortality) or Fine and Gray models (cause-specific mortality), including several potential confounders. RESULTS Five hundred and fifty-six patients died during the follow-up: 262 from cardiovascular causes, 158 from cancer and 136 from other causes. When compared with the glibenclamide users, the gliclazide and tolbutamide users showed a significantly lower cancer mortality (HR=0.30; 95% CI 0.16-0.55, and HR=0.48; 95% CI 0.29-0.79 respectively). These results were strongly confirmed in the 555 patients on sulphonylurea monotherapy. None of the patients who were treated with gliclazide monotherapy died from cancer during the follow-up, and the patients on tolbutamide treatment exhibited a lower cancer mortality than the glibenclamide users (HR=0.40; 95% CI 0.22-0.71). Data did not change after stratification for the duration of sulphonylurea treatment from diabetes diagnosis to the study enrollment. CONCLUSIONS Cancer mortality was markedly reduced in the patients on gliclazide and tolbutamide treatment. These results suggest additional benefits for these drugs beyond their blood glucose-lowering effect and strongly advocate for further investigation.
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Affiliation(s)
- Simona Bo
- Department of Internal Medicine, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy.
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Forst T, Hanefeld M, Jacob S, Moeser G, Schwenk G, Pfützner A, Haupt A. Association of sulphonylurea treatment with all-cause and cardiovascular mortality: a systematic review and meta-analysis of observational studies. Diab Vasc Dis Res 2013; 10:302-14. [PMID: 23291340 DOI: 10.1177/1479164112465442] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
We conducted a meta-analysis of cohort and case-control studies to evaluate all-cause and cardiovascular (CV) mortality of patients with type 2 diabetes mellitus (T2DM) who received sulphonylurea (SU) treatment, when compared to any other diabetes treatment. Only studies reporting raw data on mortality during SU treatment were included. Data were combined using random-effects (RE) models. Unadjusted odds ratios (ORs) are presented. Of 4991 publication titles and abstracts reviewed, 20 studies (n = 551,912 patients) were included. For cohort studies (n = 276,050), patients receiving SU monotherapy or combination treatment had significantly higher all-cause and CV mortality risks compared to any non-SU treatment [all-cause, 13 studies: OR = 1.92, 95% confidence interval (CI) = 1.48-2.49; CV, 5 studies: OR = 2.72, 95% CI = 1.95-3.79]. Validity was limited by the high treatment group heterogeneity (I (2) > 90%) and study-inherent biases/design differences. In conclusion, patients receiving SU treatment had increased all-cause and CV mortality risks. However, the meta-analysis was limited by the high heterogeneity of non-randomized studies.
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Affiliation(s)
- Thomas Forst
- Institute for Clinical Research and Development (IKFE), Mainz, Germany.
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Bell DSH. Combine and conquer: advantages and disadvantages of fixed-dose combination therapy. Diabetes Obes Metab 2013; 15:291-300. [PMID: 23013323 DOI: 10.1111/dom.12015] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 09/02/2012] [Accepted: 09/13/2012] [Indexed: 11/29/2022]
Abstract
The majority of patients with type 2 diabetes mellitus (T2DM) do not achieve the glycaemic goals recommended by leading diabetes organizations using monotherapy alone, and often require multiple antihyperglycaemic agents to achieve glycaemic control. Fixed-dose combination (FDC) therapies offer a means to simplify complex treatment regimens, and have several advantages that help patients reach their glycaemic goals. In this review, four key benefits are identified and discussed in support of FDCs for treatment of patients with T2DM: (i) Greater efficacy compared with higher dose monotherapy, (ii) Reduced risk of adverse reactions relative to higher dose monotherapy, (iii) Lower overall costs and (iv) Improved medication concordance. Given these advantages, the place of fixed combination therapy in the course of treatment is discussed. Establishing a therapeutic strategy that incorporates fixed combination therapy (including combinations with insulin) will simplify the treatment of diabetes, ideally resulting in improved medication concordance, clinical outcomes and quality of life for patients with T2DM.
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Affiliation(s)
- D S H Bell
- Southside Endocrinology, University of Alabama Medical School, Birmingham, AL, USA.
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Boussageon R, Supper I, Bejan-Angoulvant T, Kellou N, Cucherat M, Boissel JP, Kassai B, Moreau A, Gueyffier F, Cornu C. Reappraisal of metformin efficacy in the treatment of type 2 diabetes: a meta-analysis of randomised controlled trials. PLoS Med 2012; 9:e1001204. [PMID: 22509138 PMCID: PMC3323508 DOI: 10.1371/journal.pmed.1001204] [Citation(s) in RCA: 171] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Accepted: 03/02/2012] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The UK Prospective Diabetes Study showed that metformin decreases mortality compared to diet alone in overweight patients with type 2 diabetes mellitus. Since then, it has been the first-line treatment in overweight patients with type 2 diabetes. However, metformin-sulphonylurea bitherapy may increase mortality. METHODS AND FINDINGS This meta-analysis of randomised controlled trials evaluated metformin efficacy (in studies of metformin versus diet alone, versus placebo, and versus no treatment; metformin as an add-on therapy; and metformin withdrawal) against cardiovascular morbidity or mortality in patients with type 2 diabetes. We searched Medline, Embase, and the Cochrane database. Primary end points were all-cause mortality and cardiovascular death. Secondary end points included all myocardial infarctions, all strokes, congestive heart failure, peripheral vascular disease, leg amputations, and microvascular complications. Thirteen randomised controlled trials (13,110 patients) were retrieved; 9,560 patients were given metformin, and 3,550 patients were given conventional treatment or placebo. Metformin did not significantly affect the primary outcomes all-cause mortality, risk ratio (RR)=0.99 (95% CI: 0.75 to 1.31), and cardiovascular mortality, RR=1.05 (95% CI: 0.67 to 1.64). The secondary outcomes were also unaffected by metformin treatment: all myocardial infarctions, RR=0.90 (95% CI: 0.74 to 1.09); all strokes, RR=0.76 (95% CI: 0.51 to 1.14); heart failure, RR=1.03 (95% CI: 0.67 to 1.59); peripheral vascular disease, RR=0.90 (95% CI: 0.46 to 1.78); leg amputations, RR=1.04 (95% CI: 0.44 to 2.44); and microvascular complications, RR=0.83 (95% CI: 0.59 to 1.17). For all-cause mortality and cardiovascular mortality, there was significant heterogeneity when including the UK Prospective Diabetes Study subgroups (I(2)=41% and 59%). There was significant interaction with sulphonylurea as a concomitant treatment for myocardial infarction (p=0.10 and 0.02, respectively). CONCLUSIONS Although metformin is considered the gold standard, its benefit/risk ratio remains uncertain. We cannot exclude a 25% reduction or a 31% increase in all-cause mortality. We cannot exclude a 33% reduction or a 64% increase in cardiovascular mortality. Further studies are needed to clarify this situation.
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Affiliation(s)
- Rémy Boussageon
- Department of General Medicine, Université Claude Bernard Lyon 1, Lyon, France
| | - Irène Supper
- Department of General Medicine, Université Claude Bernard Lyon 1, Lyon, France
| | - Theodora Bejan-Angoulvant
- Service de Pharmacologie Clinique, Centre Hospitalier Régional et Universitaire de Tours, France
- UMR 7292, CNRS, Université François Rabelais, Tours, France
| | - Nadir Kellou
- Department of General Medicine, Université Claude Bernard Lyon 1, Lyon, France
| | - Michel Cucherat
- UMR 5558, CNRS, Laboratoire de Biométrie et Biologie Évolutive, Villeurbanne, France
- Université Claude Bernard Lyon 1, Lyon, France
| | - Jean-Pierre Boissel
- UMR 5558, CNRS, Laboratoire de Biométrie et Biologie Évolutive, Villeurbanne, France
- Université Claude Bernard Lyon 1, Lyon, France
| | - Behrouz Kassai
- UMR 5558, CNRS, Laboratoire de Biométrie et Biologie Évolutive, Villeurbanne, France
- Université Claude Bernard Lyon 1, Lyon, France
- Clinical Investigation Centre, INSERM CIC201, Lyon, France
- Department of Clinical Pharmacology, Hospices Civils de Lyon, Lyon, France
| | - Alain Moreau
- Department of General Medicine, Université Claude Bernard Lyon 1, Lyon, France
| | - François Gueyffier
- UMR 5558, CNRS, Laboratoire de Biométrie et Biologie Évolutive, Villeurbanne, France
- Université Claude Bernard Lyon 1, Lyon, France
- Clinical Investigation Centre, INSERM CIC201, Lyon, France
- Department of Clinical Pharmacology, Hospices Civils de Lyon, Lyon, France
| | - Catherine Cornu
- UMR 5558, CNRS, Laboratoire de Biométrie et Biologie Évolutive, Villeurbanne, France
- Université Claude Bernard Lyon 1, Lyon, France
- Clinical Investigation Centre, INSERM CIC201, Lyon, France
- Department of Clinical Pharmacology, Hospices Civils de Lyon, Lyon, France
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Wahlqvist ML, Lee MS, Hsu CC, Chuang SY, Lee JT, Tsai HN. Metformin-inclusive sulfonylurea therapy reduces the risk of Parkinson's disease occurring with Type 2 diabetes in a Taiwanese population cohort. Parkinsonism Relat Disord 2012; 18:753-8. [PMID: 22498320 DOI: 10.1016/j.parkreldis.2012.03.010] [Citation(s) in RCA: 161] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 02/17/2012] [Accepted: 03/15/2012] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Type 2 diabetes (T2DM) may increase the risk of Parkinson's disease (PD). We evaluated the role of oral anti-hyperglycemic agents (OAA) in any diabetes-PD linkage. METHODS From the Taiwan National Health Insurance database on 01-01-2000, a representative cohort of 800,000 was obtained between 1996-01-01 and 2007-12-31. Those ≥ 20 years were classified by presence (n = 64,166) or absence (n = 698,587) of T2DM, and whether any OAA (n = 41,003) or not (n = 23,163) was used. Those with T2DM were matched with those diabetes-free by birth-date and gender for the comparison of PD incidence. We considered those ≥ 50 years and matched PD-free diabetes patients with and without OAAs by age, gender, locality, health service, Charlson comorbidity index and T2DM diagnosis-date to avoid 'immortal time bias'. PD incidence densities (PID, per 10,000 person-years) and hazard ratios (HRs) were calculated. RESULTS HRs (95% confidence interval, CI), related to diabetes-free, were 2.18 (1.27-3.73) and 1.30 (0.77-2.19) for T2DM without and with OAAs. For sulfonylurea alone, PID (95% CI) increased from 58.3 (46.6-70.1) to 83.2 (68.6-97.7), with similar findings by gender, but little difference if metformin was used. The metformin-alone HR (95% CI) was 0.95 (0.53-1.71), sulfonylurea-alone 1.57 (1.15-2.13), and combined therapy 0.78 (0.61-1.01) and these differences persisted when incident PD was excluded for 4 years after T2DM diagnosis. The use of metformin first, in those without insulin, provided an HR of 0.40 (0.17-0.94). CONCLUSIONS Incident PD risk in T2DM increases 2.2-fold. Sulfonylureas further increase risk by 57%, which is avoided by combination with metformin.
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Affiliation(s)
- Mark L Wahlqvist
- Division of Preventive Medicine and Health Services Research, Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Miaoli, Taiwan, ROC.
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