Efficacy of glimepiride/metformin fixed-dose combination vs metformin uptitration in type 2 diabetic patients inadequately controlled on low-dose metformin monotherapy: A randomized, open label, parallel group, multicenter study in Korea

A Review on Affordable Combinations in Type 2 Diabetes Care: Exploring the Cost-Effective Potential of Glipizide + Metformin and Glimepiride + Metformin + Pioglitazone

Management of type 2 diabetes mellitus (T2DM) largely relies on medication adherence of individuals with diabetes to achieve optimal glycemic control. The economic burden of diabetes could impede adherence, leading to a reduction in treatment efficacy and increased risk of complications. Furthermore, monotherapy in diabetes is losing traction due to its ineffectiveness in achieving early and sustained optimal glycemic control in a significant proportion of the population. Hence, clinicians prefer combination treatment due to their improved efficacy and safety. Considering these factors, the current review highlights the safety and efficacy of the affordable combination therapies, a dual therapy, glipizide + metformin, and a triple-drug combination of glimepiride + metformin + pioglitazone and its applicability in the management of T2DM among individuals with diabetes in India.

Association of SLC22A1, SLC47A1, and KCNJ11 polymorphisms with efficacy and safety of metformin and sulfonylurea combination therapy in Egyptian patients with type 2 diabetes

Background and purpose

Multidrug and toxin extrusion transporter 1 (MATE1), encoded by the SLC47A1 gene and single nucleotide polymorphisms of organic cation transport 1, may impact metformin's responsiveness and side effects. Inward-rectifier potassium channel 6.2 (Kir 6.2) subunits encoded by KCNJ11 may affect the response to sulfonylurea. This study aimed to evaluate the association between SLC22A1 rs72552763 and rs628031, SLC47A1 rs2289669 and KCNJ11 rs5219 genetic variations with sulfonylurea and metformin combination therapy efficacy and safety in Egyptian type 2 diabetes mellitus patients.

Experimental approach

This study was conducted on 100 cases taking at least one year of sulfonylurea and metformin combination therapy. Patients were genotyped via the polymerase chain reaction-restriction fragment length polymorphism technique. Then, according to their glycated hemoglobin level, cases were subdivided into non-responders or responders. Depending on metformin-induced gastrointestinal tract side effects incidence, patients are classified as tolerant or intolerant.

Findings/Results

KCNJ11 rs5219 heterozygous and homozygous mutant genotypes, SLC47A1 rs2289669 heterozygous and homozygous mutant genotypes (AA and AG), and mutant alleles of both polymorphisms were significantly related with increased response to combined therapy. Individuals with the SLC22A1 (rs72552763) GAT/del genotype and the SLC22A1 (rs628031) AG and AA genotypes were at a higher risk for metformin-induced gastrointestinal tract adverse effects.

Conclusion and implications

The results implied a role for SLC47A1 rs2289669 and KCNJ11 rs5219 in the responsiveness to combined therapy. SLC22A1 (rs628031) and (rs72552763) polymorphisms may be associated with increased metformin adverse effects in type 2 diabetes mellitus patients.

Comparative Efficacy of Metformin and Glimepiride in Modulating Pharmacological Network to Increase BDNF Levels and Benefit Type 2 Diabetes-Related Cognitive Impairment

Cognitive impairment is anotable complication of type 2 diabetes (T2DM), accompanied by reduced brain-derived neurotrophic factor (BDNF) in the brain and blood. Anti-diabetic drugs reduce hyperglycemia, yet their effect on cognitive improvement is unknown. We aimed to investigate the effect of anti-diabetic drugs regulating BDNF in T2DM through computational and case-control study design. We obtained T2DMproteins viatext-mining to construct a T2DMprotein network. From the T2DMnetwork, the metformin and glimepiride interactomes and their crucial shortest-path-stimulating BDNF were identified. Using qRTPCR, the genes encoding the shortest-path proteins were assessed in four groups (untreated-T2DM, metformin-treated, glimepiride-treated, and healthy controls). Finally, ELISA was used to assess serum BDNF levels to validate drug efficacy. As a result of this investigation, aT2DMnetwork was constructed with 3683 text-mined proteins. Then, the T2DMnetwork was explored to generate a metformin and glimepiride interactome that establishes the critical shortest-path for BDNF stimulation. Metformin stimulates BDNF via APP binding to the PRKAB1 receptor. Whereas, glimepiride increases BDNF by binding to KCNJ11 via AP2M1 and ESR1 proteins. Both drug shortest-path encoding genes differed significantly between the groups. Unlike metformin, BDNF gene and protein expression rise significantly with glimepiride. Overall, glimepiride can effectively increase BDNF, which could benefit T2DM patients with cognitive deterioration.

Trends in Antidiabetic Drug Discovery: FDA Approved Drugs, New Drugs in Clinical Trials and Global Sales

Type 2 diabetes mellitus (T2DM) continues to be a substantial medical problem due to its increasing global prevalence and because chronic hyperglycemic states are closely linked with obesity, liver disease and several cardiovascular diseases. Since the early discovery of insulin, numerous antihyperglycemic drug therapies to treat diabetes have been approved, and also discontinued, by the United States Food and Drug Administration (FDA). To provide an up-to-date account of the current trends of antidiabetic pharmaceuticals, this review offers a comprehensive analysis of the main classes of antihyperglycemic compounds and their mechanisms: insulin types, biguanides, sulfonylureas, meglitinides (glinides), alpha-glucosidase inhibitors (AGIs), thiazolidinediones (TZD), incretin-dependent therapies, sodium-glucose cotransporter type 2 (SGLT2) inhibitors and combinations thereof. The number of therapeutic alternatives to treat T2DM are increasing and now there are nearly 60 drugs approved by the FDA. Beyond this there are nearly 100 additional antidiabetic agents being evaluated in clinical trials. In addition to the standard treatments of insulin therapy and metformin, there are new drug combinations, e.g., containing metformin, SGLT2 inhibitors and dipeptidyl peptidase-4 (DPP4) inhibitors, that have gained substantial use during the last decade. Furthermore, there are several interesting alternatives, such as lobeglitazone, efpeglenatide and tirzepatide, in ongoing clinical trials. Modern drugs, such as glucagon-like peptide-1 (GLP-1) receptor agonists, DPP4 inhibitors and SGLT2 inhibitors have gained popularity on the pharmaceutical market, while less expensive over the counter alternatives are increasing in developing economies. The large heterogeneity of T2DM is also creating a push towards more personalized and accessible treatments. We describe several interesting alternatives in ongoing clinical trials, which may help to achieve this in the near future.

Glucodynamics and glucocracy in type 2 diabetes mellitus: clinical evidence and practice-based opinion on modern sulfonylurea use, from an International Expert Group (South Asia, Middle East & Africa) via modified Delphi method

Type 2 diabetes mellitus (T2DM) is a global epidemic. According to international guidelines, the management protocol of T2DM includes lowering of blood glucose, along with preventing disease-related complications and maintaining optimal quality of life. Further, the guidelines recommend the use of a patient-centric approaches for the management of T2DM; however, Asian population is underrepresented in landmark cardiovascular outcome trials (CVOTs). There are several guidelines available today for the diagnosis and management of T2DM, and hence there is much confusion among practitioners about which guidelines to follow. A group of thirty international clinical experts comprising of endocrinologists, diabetologists and cardiologist from South Asia, Middle East and Africa met at New Delhi, India on February 8 and 9, 2020 and developed an international expert opinion statements via a structured modified Delphi method on the glucodynamic properties of OADs and the glucocratic treatment approach for the management of T2DM. In this modified Delphi consensus report, we document the glucodynamic properties of Modern SUs in terms of glucoconfidence, glucosafety, and gluconomics. According to glucodynamics theory, an ideal antidiabetic drug should be efficacious, safe, and affordable. Modern SUs as a class of OADs that have demonstrated optimal glucodynamics in terms of glucoconfidence, glucosafety, and gluconomics. Hence, modern SUs are most suitable second line drug after metformin for developing countries. Based on the current evidence, we recommend a glucocratic approach for the treatment of T2DM, where an individualized treatment plan with phenotype, lifestyle, environmental, social, and cultural factors should be considered for persons with T2DM in the South Asian, Middle Eastern and African regions.

Medication Adherence Assessment Among Patients with Type 2 Diabetes Mellitus Treated Polytherapy in Indonesian Community Health Center: A Cross Sectional-Study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a chronic disease where most of the patients usually need polytherapy. This could affect their medication adherence (MA). However, other complex factors may also associate with MA, which are important to identify.

AIM

The purpose of this study was to evaluate the MA of patients with T2DM who received polytherapy and to identify other factors that can affect the MA.

MATERIALS AND METHODS

This was a cross-sectional study conducted in seven community health centers in Jakarta with HbA1C representing their MA level. Poor controlled blood glucose with Hemoglobin A1C (HbA1C) of ≥7% is indicated to have low MA. All characteristics were collected to identify factors that are potentially associated with low MA. The univariate analysis tests were used to analyze factors that potentially associate with low MA. Multiple logistic regression analysis was performed in the factors to find their relationship with low MA.

RESULTS

The study obtained 143 patients with a female dominance (67.8%) and mean ± standard deviation (SD) age of 59.53 ± 9.251 years. Approximately 75.5% of the patients had low MA (HbA1C ≥ 7). Univariate analysis found that duration of T2DM significantly (P = 0.047) related to MA, where patients with T2DM of less than or equal to 5 years tended to have low MA. Logistic regression showed that patients with T2DM less than or equal to 5 years (P = 0.015, odds ratio = 1.206, 95% confidence interval = 1.216-8.014) were associated with low MA.

CONCLUSION

Patients with the duration of T2DM less than or equal to 5 years surprisingly were susceptible to have low MA. Low MA was not affected by polytherapy.

Glimepiride and Metformin Combinations in Diabetes Comorbidities and Complications: Real-World Evidence

Objective To evaluate the usage of various strengths of glimepiride and metformin fixed-dose combinations in the management of type 2 diabetes mellitus (T2DM) patients with comorbidities and complications. Methods A retrospective, non-randomized, non-comparative, multi-centric real-world study included T2DM patients (age > 18 years) taking glimepiride and metformin fixed-dose combinations. Age, duration of diabetes, diabetes complications, comorbidities (hypertension and dyslipidemia), dosage frequency, and concomitant medications were analyzed from medical charts. Results A total of 4858 T2DM patients were included, with a mean age of 52.67 years and males being predominant in the study population (60.85%). The laboratory investigations showed a mean glycated hemoglobin (HbA1c) of 7.5, low-density lipoprotein (LDL) cholesterol of 104.81 ± 38.19 mg/dL, and serum creatinine of 0.88 ± 0.26 mg/dL. Around 2055 (42.30%) T2DM patients were hypertensive, and telmisartan alone and a telmisartan-based combination were the drugs of choice for hypertension management. Similarly, 1073 (22.08%) T2DM patients were having dyslipidemia and were primarily managed with rosuvastatin and its combination in 664 (62%) patients. Macrovascular complications were observed in 339 (6.97%) T2DM patients, among which coronary artery disease (CAD) had maximum prevalence, affecting 273 (5.61%) T2DM patients. Microvascular complications were 1010 (20.79%) T2DM patients, among which neuropathy had affected a maximum of 686 (14.12%) followed by retinopathy (2.34%) and nephropathy (1.81%). Among the available 11 strengths, the glimepiride 2 mg and metformin 500 mg combination were most widely prescribed in 1297 (26.69%), followed by glimepiride 1 mg and metformin 500 mg in 1193 (24.57%) patients, and the preferred dosage pattern was twice a daily in 2665 (54.85%) T2DM patients. An age-wise prescription analysis showed that glimepiride and metformin combinations were the preferred choice for the management of diabetes across all the age groups. Conclusion The real-world evidence in the Indian clinical setting indicates that glimepiride and metformin fixed-dose combinations are widely used in the management in T2DM patients with comorbidities like hypertension, dyslipidemia, and diabetes complications. Glimepiride and metformin fixed-dose combinations are suitable for early as well as long-standing diabetes.

Myelopoiesis, metabolism and therapy: a crucial crossroads in cancer progression

Cancers promote immunological stresses that induce alterations of the myelopoietic output, defined as emergency myelopoiesis, which lead to the generation of different myeloid populations endowed with tumor-promoting activities. New evidence indicates that acquisition of this tumor-promoting phenotype by myeloid cells is the result of a multistep process, encompassing initial events originating into the bone marrow and later steps operating in the tumor microenvironment. The careful characterization of these sequential mechanisms is likely to offer new potential therapeutic opportunities. Here, we describe relevant mechanisms of myeloid cells reprogramming that instate immune dysfunctions and limit effective responses to anticancer therapy and discuss the influence that metabolic events, as well as chemotherapy, elicit on such events.

Myelopoiesis, metabolism and therapy: a crucial crossroads in cancer progression

Cancers promote immunological stresses that induce alterations of the myelopoietic output, defined as emergency myelopoiesis, which lead to the generation of different myeloid populations endowed with tumor-promoting activities. New evidence indicates that acquisition of this tumor-promoting phenotype by myeloid cells is the result of a multistep process, encompassing initial events originating into the bone marrow and later steps operating in the tumor microenvironment. The careful characterization of these sequential mechanisms is likely to offer new potential therapeutic opportunities. Here, we describe relevant mechanisms of myeloid cells reprogramming that instate immune dysfunctions and limit effective responses to anticancer therapy and discuss the influence that metabolic events, as well as chemotherapy, elicit on such events.

Comparative Effectiveness of Metformin Dosage Uptitration Versus Adding Another Antihyperglycemic Medication on Glycemic Control in Type 2 Diabetes Patients Failing Initial Metformin Monotherapy: A Retrospective Cohort Study

Metformin is recommended as first-line treatment for type 2 diabetes (T2D). A disadvantage of metformin is the possibility of gastrointestinal adverse effects in some patients. Many T2D patients are not able to achieve/maintain glycemic control from initial metformin treatment and receive treatment intensification by means of metformin dosage uptitration or addition of a T2D drug. This retrospective study evaluated the comparative effectiveness of these 2 treatment intensification strategies. The study cohort included T2D patients at a US integrated health care system who: were initiated on metformin monotherapy (MM) during January 2009 - September 2013; had an uncontrolled HbA1c (≥7%) after at least 90 days of MM; and received metformin dosage uptitration or an additional T2D medication within 6 months of the uncontrolled HbA1c reading. Statistical techniques included Kaplan-Meier curves and Cox proportional hazards regression. The study cohort included 1167 patients, 52.4% male and 65.1% white, with a mean age of 55.3 (±11.9) years. Of these, 49.1% received metformin dosage uptitration and 50.9% received an additional T2D medication. Metformin dosage uptitration was as effective as adding another T2D medication with the probability of not achieving glycemic control (P = 0.599) and rate of glycemic control (adjusted hazard ratio = 1.28, 95% confidence interval = 0.98-1.68) within 6 months of intensification not significantly different between the 2 groups. Metformin dosage uptitration could be a preferable initial intensification strategy in patients failing initial MM unless there is a concern for gastrointestinal adverse effects, in which case adding a T2D medication might be preferable.

Long-term effects on glycaemic control and β-cell preservation of early intensive treatment in patients with newly diagnosed type 2 diabetes: A multicentre randomized trial

AIM

To determine the effects of early intensive glycaemic control with intensive insulin treatment (IIT) or initial combined oral antidiabetic drug (COAD) therapy on long-term glycaemic control and the preservation of β-cell function in people with type 2 diabetes mellitus (T2DM).

METHODS

Newly diagnosed drug-naïve patients with T2DM from 8 outpatient diabetes centres were randomized to receive either IIT (n = 50; glargine/glulisine) or COAD (n = 47; glimepiride/metformin) as intensive treatment until the termination criteria to ensure euglycaemia were met. After intensive treatment, the patients completed a follow-up period with either lifestyle modification (LSM) alone or rescue therapy to maintain target glycated haemoglobin levels of <7% (53 mmol/mol) up to week 104. The primary outcomes were analysed after excluding participants who were anti-glutamic acid decarboxylase autoantibody-positive.

RESULTS

Both intensive treatment methods were effective for short-term glycaemic control, but improvements in the disposition index (DI) were significantly greater in the IIT group than in the COAD group (P = .021). During the follow-up period after intensive treatment, the two groups significantly differed in rescue method regarding the maintenance of comparable levels of glycaemic control (P = .010) and more participants who received IIT exhibited well-controlled glycaemia with LSM alone. Additionally, the IIT group maintained a higher DI than the COAD group during the follow-up period. Cox regression analysis showed that the IIT method was associated with a 52.5% lower risk of failing to maintain drug-free glycaemic remission compared with the COAD method (P = .015).

CONCLUSIONS

The findings indicate that outpatient clinic-based IIT to ensure euglycaemia in newly diagnosed patients with T2DM might be an effective initial therapeutic option for improvements in β-cell function and glycaemic control over the long term, without serious adverse events.

Rahim AA, Eliana F, Shrestha HK, Chaudhary S, Ngugi N, Mbanya JC, Aye TT, Latt TS, Akanov ZA, Syed AR, Tandon N, Unnikrishnan AG, Madhu SV, Jawa A, Chowdhury S, Bajaj S, Das AK. Consensus Recommendations on Sulfonylurea and Sulfonylurea Combinations in the Management of Type 2 Diabetes Mellitus - International Task Force

For decades, sulfonylureas (SUs) have been important drugs in the antidiabetic therapeutic armamentarium. They have been used as monotherapy as well as combination therapy. Focus on newer drugs and concerns about the risk of severe hypoglycemia and weight gain with some SUs have led to discussion on their safety and utility. It has to be borne in mind that the adverse events associated with SUs should not be ascribed to the whole class, as many modern SUs, such as glimepiride and gliclazide modified release, are associated with better safety profiles. Furthermore, individualization of treatment, using SUs in combination with other drugs, backed with careful monitoring and patient education, ensures maximum benefits with minimal side effects. The current guidelines, developed by experts from Africa, Asia, and the Middle East, promote the safe and smart use of SUs in combination with other glucose-lowering drugs.

Efficacy and safety of sitagliptin/metformin fixed-dose combination compared with glimepiride in patients with type 2 diabetes: A multicenter randomized double-blind study

BACKGROUND

Early initiation of combination therapy using antihyperglycemic agents is recommended for treating type 2 diabetes (T2D). The present multicenter double-blind randomized parallel-group study examined the efficacy and safety of a sitagliptin and metformin fixed-dose combination (Sita/Met) compared with glimepiride in T2D patients as initial treatment.

METHODS

Type 2 diabetes patients (aged ≥18 years) were randomized to Sita/Met or glimepiride for 30 weeks after a wash-off run-in period. The primary endpoint was change from baseline (CFB) in HbA1c. Secondary endpoints included the proportion of patients achieving target goal (HbA1c < 7.0 % [53 mmol/mol]) and CFB in fasting plasma glucose (FPG). Safety assessments comprised weight gain from baseline and the incidence of adverse events (AEs).

RESULTS

In total, 292 patients were randomized to Sita/Met (n = 147) or glimepiride (n = 145). After 30 weeks, Sita/Met demonstrated superiority over glimepiride in reducing HbA1c (-1.49 % vs -0.71 %, respectively; between-group difference - 0.78 %; P < 0.001). A significantly higher proportion of patients achieved the target goal with Sita/Met (81.2 %) than with glimepiride (40.1 %; P < 0.001). Greater reduction in FPG occurred with Sita/Met than with glimepiride (least-squares mean difference - 23.5 mg/dL; P < 0.001). Both drugs were generally well tolerated. Hypoglycemia events and weight gain were significantly lower in patients with Sita/Met than with glimepiride (5.5 % vs 20.1 % and -0.83 vs +0.90 kg, respectively; both P < 0.001). No serious drug-related AEs or deaths were reported.

CONCLUSIONS

Compared with glimepiride, Sita/Met as an initial treatment led to significantly greater improvements in glycemic control and body weight changes, with a lower incidence of hypoglycemia, over 30 weeks.

Place of sulfonylureas in the management of type 2 diabetes mellitus in South Asia: A consensus statement

Since their introduction in clinical practice in the 1950's, Sulfonylureas (SUs) have remained the main-stay of pharmacotherapy in the management of type 2 diabetes. Despite their well-established benefits, their place in therapy is inappropriately being overshadowed by newer therapies. Many of the clinical issues associated with the use of SUs are agent-specific, and do not pertain to the class as such. Modern SUs (glimepiride, gliclazide MR) are backed by a large body of evidence, experience, and most importantly, outcome data, which supports their role in managing patients with diabetes. Person-centred care, i.e., careful choice of SU, appropriate dosage, timing of administration, and adequate patient counseling, will ensure that deserving patients are not deprived of the advantages of this well-established class of anti-diabetic agents. Considering their efficacy, safety, pleiotropic benefits, and low cost of therapy, SUs should be considered as recommended therapy for the treatment of diabetes in South Asia. This initiative by SAFES aims to encourage rational, safe and smart prescription of SUs, and includes appropriate medication counseling.