The effect of adding metformin to insulin therapy for type 1 diabetes mellitus children: A systematic review and meta-analysis

Advancements in pharmacotherapy options for treating diabetes ‎in children and adolescents

INTRODUCTION

This study compares diabetes management between pediatric and adult patients and identifies treatment challenges and gaps.

AREAS COVERED

We searched PubMed and Clinicaltrails.gov databases for studies published from 2001 to 2023 on diabetes management in different age groups.

EXPERT OPINION

Research shows children have lower insulin sensitivity, clearance, and β cell function than adults. The US FDA only allows insulin, metformin, and liraglutide as antidiabetic medication options for children. However, some off-label drugs, like meglitinides, sulfonylureas, and alogliptin, have demonstrated positive results in treating certain types of diabetes caused by gene mutations. It's crucial to adopt personalized and precise approaches to managing diabetes in pediatrics, which vary from those used for adult patients. New studies support the classification of type 2 diabetes into several subtypes based on age, BMI, glycemia, homeostasis model estimates, varying insulin resistance, ‎different rates of complications‎, and islet ‎autoantibodies. With this insight, prevention, treatment, and precision medicine of diabetes might be changed. More research is necessary to assess the safety and efficacy of different antidiabetic drugs and improve diabetes treatment for children and adolescents.

An evidence gap map of interventions for noncommunicable diseases and risk factors among children and adolescents

Substance misuse, obesity, mental health conditions, type 1 diabetes, cancers, and cardiovascular and chronic respiratory diseases together account for 41% of disability-adjusted life years linked to noncommunicable diseases (NCDs) among children and adolescents worldwide. However, the evidence on risk factors and interventions for this age group is scarce. Here we searched four databases to generate an evidence gap map of existing interventions and research gaps for these risk factors and NCDs. We mapped 159 reviews with 2,611 primary studies; most (96.2%) were conducted in high-income countries, and only 100 studies (3.8%) were from low- and middle-income countries (LMICs). The efficacy of therapeutic interventions on biomarkers and adverse events for NCDs appears to be well evidenced. Interventions for mental health conditions appear to be moderately evidenced, while interventions for obesity and substance misuse appear to be moderate to very low evidenced. Priority areas for future research include evaluating digital health platforms to support primary NCD prevention and management, and evaluating the impact of policy changes on the prevalence of obesity and substance misuse. Our findings highlight the wide disparity of evidence between high-income countries and LMICs. There is an urgent need for increased, targeted financing to address the research gaps in LMICs.

Insulin Resistance in Adolescents and Youth With Type 1 Diabetes: A Review of Problems and Solutions

Though insulin resistance (IR) was previously considered a feature of only type 2 Diabetes (T2DM), its development in type 1 Diabetes (T1DM) is not an uncommon occurrence, the causes of which are multifactorial (gender, pubertal status, diabetes duration, ethnicity, genetics, adiposity, glycemic control, chronic inflammation). Despite improvements in glucose, blood pressure and lipid profile, vascular complications (coronary artery disease and nephropathy) continue to remain common causes of morbidity and mortality in T1DM. Aggressive glycemic control reduces but does not eliminate the risk of IR. IR accelerates the development of micro and macrovascular complications, many of which can be potentially reversed if diagnosed and managed early. Lack of endogenous insulin production makes estimation of insulin sensitivity in T1DM difficult. As hyperinsulinemic-euglycemic clamp studies are cumbersome and invasive, the use of prediction equations for calculating estimated insulin sensitivity may prove to be useful. Along with intensive insulin therapy, dietary modifications and increasing physical activity, the role of Metformin in managing IR in T1DM is becoming increasingly popular. Metformin adjunct therapy in T1DM has been shown to improve insulin sensitivity, glycemic control, lipid profile, body composition, vascular smooth muscle function, thereby reducing the risk of vascular complications, as well as reversal of early vascular dysfunction. However, further studies to assess long-term efficacy and safety of Metformin use in adolescents and youth with T1DM are needed. This review aims at revisiting the pathophysiology of IR in T1DM and techniques of identifying those at risk so as to put into action various strategies for management of the same.

Metformin: A Review of Potential Mechanism and Therapeutic Utility Beyond Diabetes

Metformin has been designated as one of the most crucial first-line therapeutic agents in the management of type 2 diabetes mellitus. Primarily being an antihyperglycemic agent, metformin also has a plethora of pleiotropic effects on various systems and processes. It acts majorly by activating AMPK (Adenosine Monophosphate-Activated Protein Kinase) in the cells and reducing glucose output from the liver. It also decreases advanced glycation end products and reactive oxygen species production in the endothelium apart from regulating the glucose and lipid metabolism in the cardiomyocytes, hence minimizing the cardiovascular risks. Its anticancer, antiproliferative and apoptosis-inducing effects on malignant cells might prove instrumental in the malignancy of organs like the breast, kidney, brain, ovary, lung, and endometrium. Preclinical studies have also shown some evidence of metformin's neuroprotective role in Parkinson's disease, Alzheimer's disease, multiple sclerosis and Huntington's disease. Metformin exerts its pleiotropic effects through varied pathways of intracellular signalling and exact mechanism in the majority of them remains yet to be clearly defined. This article has extensively reviewed the therapeutic benefits of metformin and the details of its mechanism for a molecule of boon in various conditions like diabetes, prediabetes, obesity, polycystic ovarian disease, metabolic derangement in HIV, various cancers and aging.

A combination of metformin and insulin improve cardiovascular and cerebrovascular risk factors in individuals with type 1 diabetes mellitus

BACKGROUND

This study aims to further clarify whether the addition of metformin to insulin treatment improve cardiovascular and cerebrovascular risk factors in individuals with T1DM.

METHODS

Electronic databases were searched for randomized controlled trials in which the efficacy and safety of metformin were compared with those of a placebo for risk factors of cardiovascular and cerebrovascular disease among individuals with T1DM, and a meta-analysis was conducted.

RESULTS

Thirteen cardiovascular studies were identified. In the metformin group, mean carotid intimal media thickness was significantly reduced by 0.03 mm, ascending aortic pulse wave velocity by 6.3 m/s, descending aortic wall shear stress by 1.77 dyn/cm² (P = 0.02), insulin daily dose by 0.05 U/kg/d, body weight by 2.27 kg, fat-free mass by 1.32 kg, body mass index by 0.58 kg/m², hip circumference by 0.29 m, and low-density lipoprotein by 0.16 mmol/L, all above are P < 0.05. In the metformin group, flow-mediated dilation was increased by 1.29 %, glucose infusion rate/insulin by 18.22 mg/(kg⋅min)/μIU/μL, and waist-to-hip ratio by 0.02, all above are P < 0.00001. The metformin group showed no differences in blood pressure, reactive hyperemia index, waist circumference, triglyceride, total cholesterol, high-density lipoprotein cholesterol, or body mass index Z score. For cerebrovascular studies were identified. But none of them had a risk factor assessment.

CONCLUSIONS

Metformin can ameliorate cardiovascular and cerebrovascular risk factors through non-hypoglycemic multiple pathways in individuals with T1DM.

Effect and Safety of Adding Metformin to Insulin Therapy in Treating Adolescents With Type 1 Diabetes Mellitus: An Updated Meta-Analysis of 10 Randomized Controlled Trials

Background

The role of metformin in the treatment of adolescents with type 1 diabetes mellitus (T1DM) remains controversial. We conducted this updated meta-analysis to generate a comprehensive assessment regarding the effect and safety of metformin in treating adolescents with T1DM.

Methods

We systematically searched PubMed, Embase, and the Cochrane Central Registry of Controlled Trials (CENTRAL) from their inception to November 2021 to identify randomized controlled trials evaluating the efficacy of metformin in the treatment of adolescents with T1DM. The primary outcome was the HbA1c level, and secondary outcomes included the body mass index (BMI), total insulin daily dose (TIDD) (unit/kg/d), hypoglycemia events, diabetes ketoacidosis (DKA) events, and gastrointestinal adverse events (GIAEs). Statistical analysis was conducted using RevMan 5.4 and STATA 14.0.

Results

Ten studies enrolling 539 T1DM adolescents were included. Results suggested that metformin significantly decreased the HbA1c level at 12 months (mean difference [MD])=-0.50, 95% confidence interval [CI]=-0.61 to -0.39, P < 0.01); BMI (kg/m2) at 3 months (MD=-1.05, 95%CI=-2.05 to -0.05, P=0.04); BMI z-score at 6 months (MD=-0.10, 95%CI=-0.14 to -0.06, P<0.01); and TIDD at 3 (MD=-0.13, 95%CI=-0.20 to -0.06, P<0.01), 6 (MD=-0.18, 95%CI=-0.25 to -0.11, P<0.01), and 12 (MD=-0.42, 95%CI=-0.49 to -0.35, P<0.01) months but significantly increased the risk of hypoglycemia events (risk ratio [RR]=3.13, 95%CI=1.05 to 9.32, P=0.04) and GIAEs (RR=1.64, 95%CI=1.28 to 2.10, P<0.01). For remaining outcomes at other time points, no statistical difference was identified. Sensitivity analysis confirmed the robustness of all pooled results.

Conclusions

The use of metformin might result in decreased BMI (kg/m2), BMI z-score, and TIDD and increased risk of hypoglycemia events and GIAEs in adolescents with T1DM. However, future studies are required to further confirm the optimal dose and duration of metformin therapy.

Chemokines in Type 1 Diabetes Mellitus

Background

Previous studies suggested that chemokines may play an important role in the formation and mediation of immune microenvironments of patients affected by Type 1 Diabetes Mellitus (T1DM). The aim of this study was to summarise available evidence on the associations of different chemokines with T1DM.

Methods

Following PRISMA guidelines, we systematically searched in PubMed, Web of Science, Embase and Cochrane Library databases for studies on the associations of different chemokines with T1DM. The effect size of the associations were the standardized mean differences (SMDs) with corresponding 95% confidence intervals (CIs) of the chemokines concentrations, calculated as group differences between the T1DM patients and the controls. These were summarized using network meta-analysis, which was also used to rank the chemokines by surface under cumulative ranking curve (SUCRA) probabilities.

Results

A total of 32 original studies on the association of different chemokines with T1DM were identified. Fifteen different chemokine nodes were compared between 15,683 T1DM patients and 15,128 controls, and 6 different chemokine receptor nodes were compared between 463 T1DM patients and 460 controls. Circulating samples (blood, serum, and plasma) showed that concentrations of CCL5 and CXCL1 were significantly higher in the T1DM patients than in the controls (SMD of 3.13 and 1.50, respectively). On the other hand, no significant difference in chemokine receptors between T1DM and controls was observed. SUCRA probabilities showed that circulating CCL5 had the highest rank in T1DM among all the chemokines investigated.

Conclusion

The results suggest that circulating CCL5 and CXCL1 may be promising novel biomarkers of T1DM. Future research should attempt to replicate these findings in longitudinal studies and explore potential mechanisms underlying this association.

Prevention and Management of High-Burden Noncommunicable Diseases in School-Age Children: A Systematic Review

BACKGROUND AND OBJECTIVES

Noncommunicable diseases (NCDs) are chronic conditions requiring health care, education, social and community services, addressing prevention, treatment, and management. This review aimed to summarize and synthesize the available evidence on interventions from systematic reviews of high-burden NCDs and risk factors among school-aged children.

METHODS

The following databases were used for this research: Medline, Embase, The Cochrane Library, and the Campbell library. The search dates were from 2000 to 2021. We included systematic reviews that synthesized studies to evaluate intervention effectiveness in children aged 5 to 19 years globally. Two reviewers independently extracted data and assessed methodological quality of included reviews using the AMSTAR 2 tool.

RESULTS

Fifty studies were included. Asthma had the highest number of eligible reviews (n = 19). Of the reviews reporting the delivery platform, 27% (n = 16) reported outpatient settings, 13% (n = 8) home and community-based respectively, and 8% (n = 5) school-based platforms. Included reviews primarily (69%) reported high-income country data. This may limit the results' generalizability for school-aged children and adolescents in low- and middle- income countries.

CONCLUSIONS

School-aged children and adolescents affected by NCDs require access to quality care, treatment, and support to effectively manage their diseases into adulthood. Strengthening research and the capacity of countries, especially low- and middle- income countries, for early screening, risk education and management of disease are crucial for NCD prevention and control.

Efficacy and Safety of SGLT2 Inhibitors as Adjunctive Treatment in Type 1 Diabetes in a Tertiary Care Center in Saudi Arabia

Background  Adjunctive treatment with sodium-glucose co-transporters 2 inhibitors (SGLT2- I) has been successfully used in patients with type 1 diabetes mellitus (T1DM) in recent years to improve glycemic control and reduce body weight without increasing the risk of hypoglycemia; however, there is a scarcity of evidence for real-world experience in their use in T1DM Saudi patients. The purpose of this study was to evaluate the efficacy and safety of empagliflozin as off-label adjunctive therapy in Saudi patients with T1DM. Methods  This study was a retrospective study for T1DM patients, who were prescribed empagliflozin as an adjunctive therapy. Baseline characteristics including age, changes in HbA1c, body weight, total daily insulin dose, lipid profile, and well as side effects such as urinary tract infections (UTIs) and diabetes ketoacidosis (DKA) were evaluated before and after initiation empagliflozin in 37 T1DM patients. Results  The mean age was 25.8 ± 8.0 years, mean weight was 75.3 ± 14.8 kg, mean body mass index (BMI) was 28.1 ± 6.7 kg/m 2 , mean duration of diabetes was 10.1 ± 6.5 years, and mean HbA1c was 9.4 ± 1.4%. After a mean follow-up duration of 15.8 ± 6.0 months, the mean reduction in the HbA1c% from baseline was 0.82% ( p  = 0.001) and mean weight reduction from baseline was 1.7 kg ( p  = 0.097). The total daily insulin dose was decreased by 2.9 units. UTIs and DKA episodes were reported among 2.7% and 10.8% of the participants, respectively. Conclusion  Empagliflozin in combination with insulin in overweight Saudi T1DM subjects resulted in a significant improvement in glycemic control, mild non-significant reduction in body weight, and a small but statistically significant reduction in the total daily insulin dose with a slight increase in the risk of DKA and UTIs. Further larger prospective studies are needed for better evaluation of the efficacy and safety of these agents in Saudi T1DM patients.

A century past the discovery of insulin: global progress and challenges for type 1 diabetes among children and adolescents in low-income and middle-income countries

Type 1 diabetes is on the rise globally; however, the burden of mortality remains disproportionate in low-income and middle-income countries (LMICs). As 2021 marks 100 years since the discovery of insulin, we revisit progress, global burden of type 1 diabetes trends, and understanding of the pathogenesis and management practices related to the disease. Despite much progress, inequities in access and availability of insulin formulations persist and are reflected in differences in survival and morbidity patterns related to the disease. Some of these inequities have also been exacerbated by health-system challenges during the COVID-19 pandemic. There is a clear opportunity to improve access to insulin and related essential technologies for improved management of type 1 diabetes in LMICs, especially as a part of universal health coverage. These improvements will require concerted action and investments in human resources, community engagement, and education for the timely diagnosis and management of type 1 diabetes, as well as adequate health-care financing. Further research in LMICs, especially those in Africa, is needed to improve our understanding of the burden, risk factors, and implementation strategies for managing type 1 diabetes.

Obesity in people living with type 1 diabetes

Although type 1 diabetes is traditionally considered a disease of lean people, overweight and obesity are becoming increasingly more common in individuals with type 1 diabetes. Non-physiological insulin replacement that causes peripheral hyperinsulinaemia, insulin profiles that do not match basal and mealtime insulin needs, defensive snacking to avoid hypoglycaemia, or a combination of these, are believed to affect body composition and drive excessive accumulation of body fat in people with type 1 diabetes. The consequences of overweight or obesity in people with type 1 diabetes are of particular concern, as they increase the risk of both diabetes-related and obesity-related complications, including cardiovascular disease, stroke, and various types of cancer. In this Review, we summarise the current understanding of the aetiology and consequences of excessive bodyweight in people with type 1 diabetes and highlight the need to optimise future prevention and treatment strategies in this population.

Prevalence of Metabolic Syndrome in Children and Adolescents with Type 1 Diabetes Mellitus and Possibilities of Prevention and Treatment: A Systematic Review

Overweight and obesity are an increasingly common problem, not only among the healthy population, but also in adolescents with type 1 diabetes (T1DM). Excess body weight is related to many cardiometabolic complications as well as a high risk of metabolic syndrome (MetS). The purpose of this systematic review is to provide a concise and critical overview of the prevalence of MetS in children and adolescents with T1DM and, ultimately, to discuss prevention and treatment options. The study was conducted in accordance with PRISMA guidelines. This review shows that, apart from the growing percentage of overweight and obese children and adolescents with T1DM (on average 20.1% and 9.5%, respectively), the problem of the increasing incidence of MetS (range from 3.2 to 29.9%, depending on the criteria used) is one of the most important phenomena of our time. One of the methods of prevention and treatment is a combined approach: changing eating habits and lifestyle, but there are also reports about the beneficial effects of the gut microflora.

Treating latent autoimmune diabetes in adults in the era of cardiovascular outcomes trials: Old dog should learn new tricks

BACKGROUND

Latent autoimmune diabetes in adults (LADA) is characterised by pathophysiological and clinical heterogeneity. Hence, the optimal treatment strategy for this type of diabetes remains a clinical challenge.

AIM

To discuss the potential of a modern therapeutic approach for LADA in the context of the novel findings of cardiovascular outcomes trials and stress the controversies surrounding LADA and the barriers in the effective management of people with this type of diabetes.

METHODS

We performed a literature search in major biomedical databases in order to retrieve relevant literature. The results of key studies, along with the authors' clinical experience and perspective, are summarised and discussed in this narrative, mini review article.

RESULTS

Insulin remains the primary treatment choice in individuals with low C-peptide levels. Although cardiovascular outcomes trials have mainly recruited participants with type 2 diabetes, recent data suggest that the cardiorenal protective properties of the new therapies are even present in people without diabetes and thus, the extrapolation of their results on LADA individuals sounds reasonable. Therefore, sodium-glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists should be considered for the management of people with preserved insulin production being at high cardiovascular risk. The risk of diabetic ketoacidosis with SGLT2is requires increased vigilance by treating physicians.

CONCLUSIONS

Individualisation, preservation of beta-cell mass and function and cardiorenal protection are the new challenges in LADA therapy.

Improvement Effect of Metformin on Female and Male Reproduction in Endocrine Pathologies and Its Mechanisms

Metformin (MF), a first-line drug to treat type 2 diabetes mellitus (T2DM), alone and in combination with other drugs, restores the ovarian function in women with polycystic ovary syndrome (PCOS) and improves fetal development, pregnancy outcomes and offspring health in gestational diabetes mellitus (GDM) and T2DM. MF treatment is demonstrated to improve the efficiency of in vitro fertilization and is considered a supplementary drug in assisted reproductive technologies. MF administration shows positive effect on steroidogenesis and spermatogenesis in men with metabolic disorders, thus MF treatment indicates prospective use for improvement of male reproductive functions and fertility. MF lacks teratogenic effects and has positive health effect in newborns. The review is focused on use of MF therapy for restoration of female and male reproductive functions and improvement of pregnancy outcomes in metabolic and endocrine disorders. The mechanisms of MF action are discussed, including normalization of metabolic and hormonal status in PCOS, GDM, T2DM and metabolic syndrome and restoration of functional activity and hormonal regulation of the gonadal axis.

Preventing Cardiovascular Complications in Type 1 Diabetes: The Need for a Lifetime Approach

Cardiovascular disease (CVD) remains the main cause of morbidity and mortality in individuals with type 1 diabetes (T1D). Adolescence appears to be a critical time for the development of early subclinical manifestations of CVD, with these changes likely driven by a deterioration in glycemic control during the progression through puberty, combined with the emergence of numerous other traditional cardiometabolic risk factors (e.g., hypertension, dyslipidemia, smoking, alcohol use, obesity, etc.) which emerge at this age. Although hemoglobin A1C has long been the primary focus of screening and treatment strategies, glycemic control remains poor in youth with T1D. Furthermore, screening for cardiovascular risk factors-which are often elevated in youth with T1D-is suboptimal, and use of pharmacological interventions for hypertension and dyslipidemia remains low. As such, there is a clear need not only for better screening strategies for CVD risk factors in youth, but also early interventions to reduce these, if future CVD events have to be prevented. Accumulating evidence has recently suggested that early increases in urinary albumin excretion, even within the normal range, may identify adolescents with T1D who are at an increased risk of complications, and results from pharmacological intervention with statins and ACE inhibitors in these individuals have been encouraging. These data join a growing evidence highlighting the need for a whole-life approach to prevention starting from childhood if efforts to improve CVD outcomes and related mortality in T1D are to be maintained.

Pharmacotherapy of Children and Adolescents with Type 1 Diabetes Mellitus

Insulin treatment in children and adolescents with autoimmune type 1 diabetes has changed tremendously in the last 20 years with the knowledge of DCCT trial regarding near-normal glucose levels on the micro- and macrovascular outcome. Intensified insulin therapy is now standard of care. Carb counting however was introduced systematically only recently in several countries. In industrialized countries most patients in this age group are treated with continuous subcutaneous insulin injections. Nowadays this is combined with continuous subcutaneous glucose measurement commencing sensor-augmented pump therapy. Predictive low glucose suspend reduces the frequency of hypoglycemic events. Still not available for children is a commercially available closed loop system. However, treatment goals are still frequently not reached especially in the group of adolescents. Therefore several additive drugs are tested to improve treatment results. There are new insulins with faster and longer action profile in the pipeline to better mimic physiologic insulin profiles. Smart insulins may be able to mimic reaction on blood sugar levels. The broad facet of treatment modalities helps pediatric diabetes teams to individualize therapy and so improve patients' health-related quality of life.

Vascular and metabolic effects of metformin added to insulin therapy in patients with type 1 diabetes: A systematic review and meta-analysis

BACKGROUND

The incidence of type 1 diabetes mellitus (T1DM) is increasing among youth worldwide, translating to an increased risk ofearly-onset cardiovascular disease (CVD). Mounting studies have shown that metformin may reduce maximal carotidintima-media thickness (cIMT), improve insulin resistance and metabolic control in subjects with T1DM, and thus, may extend cardioprotective benefits. This systematic review and meta-analysis was performed to assess the efficacy and safety of metformin added to insulin therapy on reducing CVD risks and improving metabolism in T1DM.

METHODS

PubMed, EMBASE, and the Cochrane Library were systematically searched for randomized controlled trials (RCTs) that compared metformin and insulin combination (duration ≥3 months) to insulin treatment alone in T1DM. Data were expressed as weighted/standardized mean differences (MDs/SMDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes, along with 95% confidence intervals (CIs). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to evaluate the overall certainty of the evidence.

RESULTS

Nineteen RCTs (n = 1540) met the eligibility criteria. Metformin treatment significantly reduced carotid artery intima-media thickness (MD -0.06 mm [95% CI -0.88, -0.28], P < .001). Though no significant difference was found in insulin sensitivity (SMD 2.21 [95% CI -1.88, 6.29], P = .29), the total daily insulin dosage (SMD -0.81 [95% CI -1.25, -0.36], P < .001) along with traditional CVD risk factors showed improvement by better glycaemic control, partial lipid profiles, diastolic blood pressure, and limited weight gain, with neutral effect on diabetic ketoacidosis, lactic acidosis, and hypoglycaemia. However, metformin therapy increased the incidence of gastrointestinal adverse events.

CONCLUSIONS

Metformin with insulin has the potential to retard the progression of atherosclerosis and provides better metabolic control in patients with T1DM, and thus, providing a potential therapeutic strategy for patients with T1DM on reducing CVD risks.

Mechanisms of diabetic cardiomyopathy and potential therapeutic strategies: preclinical and clinical evidence

The pathogenesis and clinical features of diabetic cardiomyopathy have been well-studied in the past decade, but effective approaches to prevent and treat this disease are limited. Diabetic cardiomyopathy occurs as a result of the dysregulated glucose and lipid metabolism associated with diabetes mellitus, which leads to increased oxidative stress and the activation of multiple inflammatory pathways that mediate cellular and extracellular injury, pathological cardiac remodelling, and diastolic and systolic dysfunction. Preclinical studies in animal models of diabetes have identified multiple intracellular pathways involved in the pathogenesis of diabetic cardiomyopathy and potential cardioprotective strategies to prevent and treat the disease, including antifibrotic agents, anti-inflammatory agents and antioxidants. Some of these interventions have been tested in clinical trials and have shown favourable initial results. In this Review, we discuss the mechanisms underlying the development of diabetic cardiomyopathy and heart failure in type 1 and type 2 diabetes mellitus, and we summarize the evidence from preclinical and clinical studies that might provide guidance for the development of targeted strategies. We also highlight some of the novel pharmacological therapeutic strategies for the treatment and prevention of diabetic cardiomyopathy.

Treatment of cardiometabolic risk factors in patients with type 1 diabetes

PURPOSE OF REVIEW

Individuals with type 1 diabetes (T1D) have excess cardiovascular risk and reduced life expectancy. Adolescence is the time when the first signs of vascular complications appear and a critical window for interventions. This article reviews recent evidence on cardiometabolic risk factors and their management in youth with T1D.

RECENT FINDINGS

Adolescents with T1D show early signs of vascular complications, as a result of several cardiometabolic risk factors. Poor glycemic control is one of the main risk factors and the main target of treatment. However, only a minority of adolescents with T1D reaches recommended targets for glycemic control. Hypertension, dyslipidemia, smoking, alcohol use, obesity and insulin resistance are other common cardiometabolic risk factors in this age group. Recent data confirm that screening for these risk factors is suboptimal and use of pharmacological interventions for hypertension and dyslipidemia remains low. Data on adjunctive noninsulin agents to improve glycemic control and other cardiometabolic risk factors are still lacking in this age group.

SUMMARY

Vascular complications and the associated mortality remain a major issue for youth with T1D. Better screening strategies for cardiometabolic risk factors and interventions are required to improve the long-term prognosis of youth with T1D.

Metformin Therapy Reduces Obesity Indices in Children and Adolescents: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Purpose: Few studies have summarized findings for the effect of metformin on obesity indices. Therefore, we aimed to conduct a systematic review and meta-analysis on the effect of metformin on obesity indices among children and adolescents. Methods: Relevant articles published up to September 2018 were searched in SCOPUS, Medline, and Google Scholar using appropriate keywords. All clinical trials that examined the effect of metformin on obesity indices in children and adolescents were included. Results: Overall, 38 studies, including 2199 participants (39.75% male and 60.25% female), were included. The pooled results indicated that metformin significantly reduced BMI [weighted mean difference (WMD): -1.07 kg/m²; 95% confidence interval (CI): -1.43 to -0.72]. Same findings were found for waist circumference (WC) (WMD: -1.93 cm; 95% CI: -2.69 to -1.16). Metformin also reduced body weight in all participants (WMD: -2.51 kg; 95% CI: -3.14 to -1.89). Moreover, it reduced body fat mass in patients with overweight or obesity (WMD: -1.90%; 95% CI: -3.25 to -0.56) and chronic diseases (WMD: -1.41%; 95% CI: -2.23 to -0.58), but not among those with growth problems. Metformin therapy did not affect lean body mass (LBM) in patients with overweight or obesity and growth problems; however, it reduced LBM in patients with chronic diseases (WMD: -1.49 kg; 95% CI: -2.69 to -0.30). Conclusions: We found a significant reduction in BMI, body weight, WC, and fat mass following administration with metformin. However, the effect of metformin on LBM was not significant. Further studies are required to confirm these findings.

Therapeutic approaches for latent autoimmune diabetes in adults: One size does not fit all

Recent advances in the understanding of latent autoimmune diabetes in adults (LADA) pathophysiology make it increasingly evident that people with LADA comprise a heterogenous group of patients. This makes the establishment of a standard treatment algorithm challenging. On top of its glucose-lowering action, insulin may exert anti-inflammatory effects, rendering it an attractive therapeutic choice for a type of diabetes in which autoinflammation and beta cell insufficiency play major pathogenetic roles. However, there is growing evidence that other antidiabetic drugs, such as metformin, dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists, and thiazolidinediones, might have a role in optimizing glycemic control and preserving beta cell function in individuals with LADA, either alone or in combination with insulin. Although most of these drugs have been routinely used in the daily clinical setting for years, large prospective randomized trials are needed to assess whether they are capable of delaying progression to insulin dependence as well as their effects on diabetic complications. The aim of the present review is to discuss the current state and future perspectives of LADA therapy, emphasizing the need for individualized and patient-centered therapeutic approaches.

Effects of Metformin Added to Insulin in Adolescents with Type 1 Diabetes: An Exploratory Crossover Randomized Trial

BACKGROUND

To comprehensively assess the effects of metformin added to insulin on metabolic control, insulin sensitivity, and cardiovascular autonomic function in adolescents with type 1 diabetes.

MATERIALS AND METHODS

This was an exploratory, crossover, randomized trial conducted in adolescents with type 1 diabetes aged 12-18 years old. Participants were randomly received metformin (≤1000 mg/d) added to insulin for 24 weeks followed by insulin monotherapy for a subsequent 24 weeks or vice versa. Blood pressure, body mass index, insulin dose, estimated insulin sensitivity, glycated hemoglobin A1c (HbA1c), and lipid profiles were measured, with a 72-hour continuous glucose monitoring and 24-hour Holter monitoring performed at baseline, 24, and 50 weeks for the assessments of glucose variability and heart rate variability.

RESULTS

Seventeen patients with mean ± SD age 14.4 ± 2.3 years, body mass index 18.17 ± 1.81 kg/m², median (IQR) diabetes duration 4.50 (3.58, 6.92) years, and HbA1c 9.0% (8.5%, 9.4%) were enrolled. The between-group difference in HbA1c of 0.28% (95% CI -0.39 to 0.95%) was not significant (P = 0.40). Changes in body mass index, insulin dose, blood pressure, lipid profiles, and estimated insulin sensitivity were similar for metformin add-on vs. insulin monotherapy. Glucose variability also did not differ. Compared with insulin monotherapy, metformin add-on significantly increased multiple heart rate variability parameters.

CONCLUSIONS

Metformin added to insulin did not improve metabolic control or glucose variability in lean/normal-weight adolescents with type 1 diabetes. However, metformin added to insulin significantly increased heart rate variability, suggesting that metformin might improve cardiovascular autonomic function in this population.

Effects of Sodium-Glucose Cotransporter Inhibitor/Glucagon-Like Peptide-1 Receptor Agonist Add-On to Insulin Therapy on Glucose Homeostasis and Body Weight in Patients With Type 1 Diabetes: A Network Meta-Analysis

Many patients with type 1 diabetes (T1D) do not achieve the glycemic target goal with insulin treatment. In this study, we aimed to evaluate the efficacy and safety of add-on to insulin therapy in patients with T1D. We conducted direct and indirect network meta-analyses using Bayesian models and ranked hypoglycemic agents via mixed treatment comparison, using data from the CENTRAL, MEDLINE, EMBASE, and Science Citation Index Expanded databases. Randomized controlled trials (RCTs) involving patients with T1D treated with insulin and add-on metformin or sodium-glucose cotransporter inhibitors or glucagon-like peptide-1 receptor agonists from January 1970 to September 2019 were included in this study. Twenty-three RCTs with 5,151 subjects were divided into the following groups: insulin alone, insulin+metformin, insulin+canagliflozin, insulin+dapagliflozin, insulin+empagliflozin, insulin+sotagliflozin, insulin+liraglutide, and insulin+exenatide. HbA1c level in the insulin+sotagliflozin group was significantly lower than that in the insulin alone group (mean difference: -0.43, 95% credible interval: -0.62 to -0.23). Total daily insulin dose in the insulin+sotagliflozin group was significantly lower than that in the insulin alone group. Compared with that in the insulin alone group, body weight in the groups treated with insulin+add-on canagliflozin, sotagliflozin, and exenatide was significantly decreased by 4.5, 2.8, and 5.1 kg, respectively. Hypoglycemic episodes did not differ among the groups. In patients with T1D, insulin+sotagliflozin decreased the HbA1c level, daily insulin dose, and body weight without hypoglycemia compared with insulin monotherapy. Insulin+canagliflozin or insulin+exenatide was effective in reducing body weight compared with insulin alone. In conclusion, sotagliflozin treatment decreased not only the HbA1c levels and insulin dose but also the body weight without causing hypoglycemia in patients with T1D. Treatment with canagliflozin and exenatide effectively reduced body weight in patients with T1D. However, ketoacidosis associated with the use of SGLT inhibitors should be considered in these patients. Thus, our results suggest that sotagliflozin has a high probability of being ranked first as an adjunctive therapy to insulin in patients with T1D.

Metformin Improves Insulin Sensitivity and Vascular Health in Youth With Type 1 Diabetes Mellitus

BACKGROUND

Cardiovascular disease is the leading cause of mortality in type 1 diabetes mellitus (T1DM) and relates strongly to insulin resistance (IR). Lean and obese adolescents with T1DM have marked IR. Metformin improves surrogate markers of IR in T1DM, but its effect on directly measured IR and vascular health in youth with T1DM is unclear. We hypothesized that adolescents with T1DM have impaired vascular function and that metformin improves this IR and vascular dysfunction.

METHODS

Adolescents with T1DM and control participants underwent magnetic resonance imaging of the ascending (AA) and descending aorta to assess pulse wave velocity, relative area change, and maximal (WSS_MAX) and time-averaged (WSS_TA) wall shear stress. Participants with T1DM also underwent assessment of carotid intima-media thickness by ultrasound, brachial distensibility by DynaPulse, fat and lean mass by dual-energy x-ray absorptiometry, fasting laboratories after overnight glycemic control, and insulin sensitivity by hyperinsulinemic-euglycemic clamp (glucose infusion rate/insulin). Adolescents with T1DM were randomized 1:1 to 3 months of 2000 mg metformin or placebo daily, after which baseline measures were repeated.

RESULTS

Forty-eight adolescents with T1DM who were 12 to 21 years of age (40% body mass index [BMI] ≥90th percentile; 56% female) and 24 nondiabetic control participants of similar age, BMI, and sex distribution were enrolled. Adolescents with T1DM demonstrated impaired aortic health compared with control participants, including elevated AA and descending aorta pulse wave velocity, reduced AA and descending aorta relative area change, and elevated AA and descending aorta WSS_MAX and WSS_TA. Adolescents with T1DM in the metformin versus placebo group had improved glucose infusion rate/insulin (12.2±3.2 [mg·kg^-1·min^-1]/μIU/μL versus -2.4±3.6 [mg·kg^-1·min^-1]/μIU/μL, P=0.005; 18.6±4.8 [mg·lean kg^-1·min^-1]/μIU/μL versus -3.4±5.6 [mg·lean kg^-1·min^-1]/μIU/μL, P=0.005) and reduced weight (-0.5±0.5 kg versus 1.6±0.5 kg; P=0.004), BMI (-0.2±0.15 kg/m² versus 0.4±0.15 kg/m²; P=0.005), and fat mass (-0.7±0.3 kg versus 0.6±0.4 kg; P=0.01). Glucose infusion rate/insulin also improved in normal-weight participants (11.8±4.4 [mg·kg^-1·min^-1]/μIU/μL versus -4.5±4.4 [mg·kg^-1·min^-1]/μIU/μL, P=0.02; 17.6±6.7 [mg·lean kg^-1·min^-1]/μIU/μL versus -7.0±6.7 [mg·lean kg^-1·min^-1]/μIU/μL, P=0.02). The metformin group had reduced AA WSS_MAX (-0.3±0.4 dyne/cm² versus 1.5±0.5 dyne/cm²; P=0.03), AA pulse wave velocity (-1.1±1.20 m/s versus 4.1±1.6 m/s; P=0.04), and far-wall diastolic carotid intima-media thickness (-0.04±0.01 mm versus -0.00±0.01 mm; P=0.049) versus placebo.

CONCLUSIONS

Adolescents with T1DM demonstrate IR and impaired vascular health compared with control participants. Metformin improves IR, regardless of baseline BMI, and BMI, weight, fat mass, insulin dose, and aortic and carotid health in adolescents with T1DM. Metformin may hold promise as a cardioprotective intervention in T1DM.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01808690.

Association of metformin and statin medications with surrogate measures of cardiovascular disease in youth with type 1 diabetes: the SEARCH for diabetes in youth study

PURPOSE

Youth with type 1 diabetes mellitus (T1DM) are at risk of cardiovascular disease (CVD). We evaluated if metformin or statin use was associated with surrogate measures of improved CVD.

METHODS

We included participants from the SEARCH observational study. Participants treated with insulin plus metformin (n=42) or insulin plus statin (n=39) were matched with 84 and 78 participants, respectively, treated with insulin alone. Measures of arterial stiffness obtained were pulse wave velocity (PWV), augmentation index (AI75), and heart rate variability as standard deviation of the normal-to-normal interval (SDNN) and root mean square differences of successive NN intervals (RMSSD).

RESULTS

CVD measures were not significantly different among participants on insulin plus metformin versus those on insulin alone: PWV (5.9±1.0 m/sec vs. 5.8±1.5 m/sec, P=0.730), AI75 (1.8 [-6.0 to 8.0] vs. -2.4 [-10.7 to 3.8], P=0.157), SDNN (52.4 [36.8-71.1] m/sec vs. 51.8 [40.1-74.9] m/sec, P=0.592), and RMSSD (43.2 [29.4-67.6] vs. 47.4 [28.0-76.3], P=0.952). CVD measures were not different for statin users versus nonusers: PWV (5.7±0.8 m/sec vs. 5.9 ±1.1 m/sec, P=0.184), AI75 ( -4.0 [-9.5 to 1.7] vs. -6.7 [-11.3 to 5.7], P=0.998), SDNN (54.6 [43.5-77.2] m/sec vs. 63.1 [44.2-86.6] m/sec, P=0.369), and RMSSD (49.5 [31.2-74.8] vs. 59.2 [38.3-86.3], P=0.430).

CONCLUSION

We found no associations of statin or metformin use with surrogate measures of CVD. Future prospective pediatric clinical trials could address this issue.

Metformin Improves Peripheral Insulin Sensitivity in Youth With Type 1 Diabetes

CONTEXT

Type 1 diabetes in adolescence is characterized by insulin deficiency and insulin resistance (IR), both thought to increase cardiovascular disease risk. We previously demonstrated that adolescents with type 1 diabetes have adipose, hepatic, and muscle IR, and that metformin lowers daily insulin dose, suggesting improved IR. However, whether metformin improves IR in muscle, hepatic, or adipose tissues in type 1 diabetes was unknown.

OBJECTIVE

Measure peripheral, hepatic, and adipose insulin sensitivity before and after metformin or placebo therapy in youth with obesity with type 1 diabetes.

DESIGN

Double-blind, placebo-controlled clinical trial.

SETTING

Multi-center at eight sites of the T1D Exchange Clinic Network.

PARTICIPANTS

A subset of 12- to 19-year-olds with type 1 diabetes (inclusion criteria: body mass index ≥85th percentile, HbA1c 7.5% to 9.9%, insulin dosing ≥0.8 U/kg/d) from a larger trial (NCT02045290) were enrolled.

INTERVENTION

Participants were randomized to 3 months of metformin (N = 19) or placebo (N = 18) and underwent a three-phase hyperinsulinemic euglycemic clamp with glucose and glycerol isotope tracers to assess tissue-specific IR before and after treatment.

MAIN OUTCOME MEASURES

Peripheral insulin sensitivity, endogenous glucose release, rate of lipolysis.

RESULTS

Between-group differences in change in insulin sensitivity favored metformin regarding whole-body IR [change in glucose infusion rate 1.3 (0.1, 2.4) mg/kg/min, P = 0.03] and peripheral IR [change in metabolic clearance rate 0.923 (-0.002, 1.867) dL/kg/min, P = 0.05]. Metformin did not impact insulin suppression of endogenous glucose release (P = 0.12). Adipose IR was not assessable with traditional methods in this highly IR population.

CONCLUSIONS

Metformin appears to improve whole-body and peripheral IR in youth who are overweight/obese with type 1 diabetes.

Effect of metformin on clinical and biochemical hyperandrogenism in adolescent girls with type 1 diabetes

Background Hyperandrogenism with or without polycystic ovarian syndrome is seen in adolescents with type 1 diabetes (T1D), especially those with suboptimal control. Objective To assess the effect of metformin on hyperandrogenism and ovarian function in adolescents with T1D. Methods This prospective study included 28 T1D females showing signs of hyperandrogenism. History taking (detailed diabetes history and menstrual history) and anthropometric measurements (weight, height, body mass index [BMI], waist and hip circumference) were initially performed, and then the patients were assessed for the manifestations of hyperandrogenism (acne, hirsutism as well as pelvic ultrasound [U/S] for ovarian morphology). Biochemical evaluation for ovulation (progesterone assessment during the luteal phase), sex steroids (estradiol, testosterone, dehydroepiandrosterone sulfate [DHEAS] and androstenedione), prolactin, glycemic control (hemoglobin A1c [HbA1c]) and gonadotropin levels (follicle stimulating hormone [FSH] and luteinizing hormone [LH]) was done. Patients were subjected to 500 mg metformin twice daily orally for 1 year, and then the patients were re-evaluated for clinical and biochemical parameters. Results Metformin therapy resulted in a significant reduction in weight (p = 0.001), BMI (p = 0.002), acne (p = 0.008), hirsutism score (0.007), LH (p = 0.008), testosterone (p < 0.001) and androstenedione levels (p = 0.028) in adolescent girls with T1D. Regarding menstrual irregularities, there was a significant reduction in the number of patients with oligomenorrhea (68%) with a p value of <0.001. However, there were no significant reduction in the daily insulin requirements (p = 0.782) or HbA1c (p = 0.068). Nausea and/or abdominal pain were the commonly reported side effects of metformin (64%). Conclusions Metformin as an insulin sensitizing agent improved the BMI and cycle regularity together with clinical and biochemical hyperandrogenism in T1D adolescent girls. However, it did not improve their glycemic control.

Pharmacologic adjunctive to insulin therapies in type 1 diabetes: The journey has just begun

Treatment of type 1 diabetes (T1D) is currently based exclusively on insulin replacement therapy. However, there is a need for better glycemic control, lower hypoglycemia rates, more effective weight management, and further reduction of cardiovascular risk in people with T1D. In this context, agents from the pharmaceutical quiver of type 2 diabetes are being tested in clinical trials, as adjunctive to insulin therapies for T1D patients. Despite the limited amount of relevant evidence and the inter-class variability, it can be said that these agents have a role in optimizing metabolic control, assisting weight management and reducing glycemic variability in people with T1D. Specific safety issues, including the increased risk of hypoglycemia and diabetic ketoacidosis, as well as the effects of these treatments on major cardiovascular outcomes should be further assessed by future studies, before these therapeutic choices become widely available for T1D management.

Empagliflozin in type 1 diabetes

There is a clear unmet need in people living with type 1 diabetes (T1D). Although the quality of life of people with T1D has improved, issues like hypoglycemia, weight gain and variability in glucose profiles remain. In this review, the clinical efficacy and safety of empagliflozin, a sodium-glucose cotransporter type 2 (SGLT2) inhibitor in T1D, is described based on a review of phase 2 and 3 studies to date. Empagliflozin and SGLT2 inhibitors, in general, are effective glucose-lowering drugs, which also work in people with T1D. Recent phase II and III studies, including the EASE trials for empagliflozin, showed a clear beneficial effect on HbA1c, body weight, glucose variability and total daily insulin use in people with T1D. No increase in hypoglycemia risk, in particular severe hypoglycemia, was observed, but genital infections were more prevalent. The use of SGLT2 inhibitors comes with a decrease in insulin doses, making individuals more prone to diabetic ketoacidosis (DKA). The uniqueness of the EASE program is that here, a very low dose of empagliflozin was used, with less, but still present, effects on metabolic outcomes, but interestingly a lower risk of DKA. Importantly, even in the higher doses of empagliflozin, it is clear that the overall risk for DKA remains low, most likely by educating patients and caretakers intensively on this subject. In conclusion, evidence is building on the potential of using empagliflozin, like other SGLT2 inhibitors, in T1D. However, to date, the use of empagliflozin is not approved in people with T1D. Clinicians will have to weigh the potential short- and long-term benefits of these adjunct therapies versus the potential acute side effects, in particular, the small but real risk of DKA in the individual T1D patient.

Environmental Factors Associated With Type 1 Diabetes

Type 1 diabetes (T1D) is a chronic autoimmune disorder that leads to progressive pancreatic ß-cell destruction and culminates in absolute insulin deficiency and stable hyperglycaemia. It is very likely that environmental factors play a role in triggering islet autoimmunity. Knowing whether they have true relevance in favoring T1D development is essential for the effective prevention of the disease. Moreover, prevention could be obtained directly interfering with the development of autoimmunity through autoantigen-based immunotherapy. In this narrative review, the present possibilities for the prevention of T1D are discussed. Presently, interventions to prevent T1D are generally made in subjects in whom autoimmunity is already activated and autoantibodies against pancreatic cell components have been detected. Practically, the goal is to slow down the immune process by preserving the normal structure of the pancreatic islets for as long as possible. Unfortunately, presently methods able to avoid the risk of autoimmune activation are not available. Elimination of environmental factors associated with T1D development, reverse of epigenetic modifications that favor initiation of autoimmunity in subjects exposed to environmental factors and use of autoantigen-based immunotherapy are possible approaches, although for all these measures definitive conclusions cannot be drawn. However, the road is traced and it is possible that in a not so distant future an effective prevention of the disease to all the subjects at risk can be offered.

Evolving Pharmacotherapeutic Strategies for Type 1 Diabetes Mellitus

Despite pharmacotherapeutic advancements in the management of type 1 diabetes mellitus during the past several decades, patients struggle to achieve glycemic goals. Additionally, hypoglycemia, especially in extremes of age, decreases quality of life. The lack of optimal glycemic control and risk for hypoglycemia are multifactorial. Nevertheless, endeavors aiming to develop pharmacotherapeutic options with enhanced pharmacokinetic, pharmacodynamic, and clinical profiles continue. This review article discusses recent ventures in 3 categories of insulin, non-insulin, and glucagon products.

Commentary on the Impact of Obesity on PediatricDiabetes

While conventionally most children diagnosed with diabetes are thought to have type 1 diabetes mellitus (T1DM), with the increased prevalence of obesity, more are being affected by type 2 (T2) DM. Obesity leads to increased insulin resistance, which over time can lead to progressive β-cell failure and ultimately T2DM. However, patients developing T1DM may also be obese, making both the proper classification and management of diabetes in children more challenging. In this commentary, the authors discuss the impact ofobesity on the presentation of pediatric diabetes, how to differentiate between T1DM and T2DM, and the proper management of both diseases.

Empagliflozin as adjunct to insulin in Japanese participants with type 1 diabetes: Results of a 4-week, double-blind, randomized, placebo-controlled phase 2 trial

AIMS

This phase 2, double-blind, randomized, placebo-controlled trial (ClinicalTrials.gov NCT02702011) with 4 sites in Japan investigated the pharmacodynamics (PD), pharmacokinetics (PK) and safety profile of empagliflozin in Japanese participants with type 1 diabetes mellitus (T1DM) as adjunctive therapy to insulin.

MATERIALS AND METHODS

Participants using multiple daily injections of insulin for ≥12 months, with HbA1c of 7.5%-10.0%, entered a 2-week, open-label, placebo run-in period, followed by a 4-week, double-blind period during which participants were randomized 1:1:1:1 to receive empagliflozin 2.5 mg (n = 13), empagliflozin 10 mg (n = 12), empagliflozin 25 mg (n = 12) or placebo (n = 11). The primary objective was to assess the effect of empagliflozin vs placebo on urinary glucose excretion (UGE) after 7 days of treatment.

RESULTS

PD: Empagliflozin resulted in a dose-dependent significant increase in 24-hour UGE compared with placebo (UGE placebo-corrected mean [95% confidence interval] change from baseline: 2.5 mg, 65.10 [43.29, 86.90] g/24 h; 10 mg, 81.19 [58.80, 103.58] g/24 h; 25 mg, 98.11 [75.91, 120.31] g/24 h). After 4 weeks of treatment, UGE increase was associated with improved glycaemic control, reduced body weight and decreased insulin needs. Empagliflozin treatment also resulted in dose-dependent increases in serum ketone bodies and free fatty acids. PK: Plasma empagliflozin levels increased in a dose-dependent manner and peaked at 1.5 hours. In this short study, empagliflozin was well tolerated, with no increase in rate of hypoglycaemia and no diabetic ketoacidosis events reported.

CONCLUSIONS

Based on this short-duration phase 2 study, the PK/PD profile of empagliflozin in Japanese participants with T1DM is comparable to that of non-Japanese participants.

Adjuvant Pharmacotherapies to Insulin for the Treatment of Type 1 Diabetes

PURPOSE OF REVIEW

Insulin therapy alone fails to achieve target glycemic control in the majority of individuals with type 1 diabetes (T1D), motivating the investigation of additive medications. This review focuses on the recent findings on the use of adjunctive pharmacotherapy in T1D.

RECENT FINDINGS

Metformin and glucagon-like peptide-1 receptor agonists have been associated with weight reduction and decrease in daily insulin requirements without sustainable improvement in glycemic control. Sodium-glucose cotransporter (SGLT)-2 inhibitors, dual SGLT-1/2 inhibitors, and pramlintide have been shown to reduce hemoglobin A1c, induce weight loss, and lower insulin dose. The benefits of dipeptidyl peptidase-4 inhibitors, thiazolidinediones, and alpha glucosidase inhibitors appear to be more limited. Gastrointestinal symptoms and increased hypoglycemia are adverse effects of certain classes. Although not devoid of side effects, additive pharmacotherapies in T1D can improve glycemic control and lower body weight and insulin requirement. Longer studies are needed before consideration for widespread clinical care.

Effect of metformin on glycaemic control in patients with type 1 diabetes: A meta-analysis of randomized controlled trials

BACKGROUND

For type 1 diabetes (T1D) patients, adding metformin to insulin therapies is thought to improve blood glucose levels, but current evidence does not support this clinical benefit. Additional data from large clinical trials are now available; therefore, we conducted a meta-analysis of studies on assessing the efficacy and adverse effects of metformin.

METHODS

We searched the MEDLINE, EMBASE, and Cochrane Library databases for data from randomized controlled trials. We performed statistical analyses by using Review Manager 5.2.

RESULTS

Thirteen randomized controlled trials that compared metformin versus placebo met our inclusion criteria and were included in the study. The final meta-analysis included a total of 1183 participants with T1D. Metformin was associated with reductions in BMI (-1.14, 95% CI -2.05 to -0.24, P = .01), insulin requirements (-0.47, 95% CI -0.70 to -0.23, P = .0001), total cholesterol (-0.23, 95% CI -0.34 to -0.12, P < .0001), and low-density lipoprotein cholesterol (-0.20, 95% CI -0.29 to -0.11, P < .0001) in T1D patients. No clear evidence indicated that metformin improved HbA1c, triglyceride, or high-density lipoprotein cholesterol levels. A safety analysis showed that metformin slightly increased the risk of severe hypoglycaemia (1.23, 95% CI 1.00 to 1.52, P = .05) and mainly gastrointestinal adverse events (2.67, 95% CI 2.06 to 3.45, P < .00001). No evidence showed that metformin increased diabetic ketoacidosis events.

CONCLUSIONS

Compared with placebo, metformin was not associated with glycaemic control in T1D patients. Although it exhibited other benefits, such as lower BMI and reduced insulin requirements, total cholesterol, and low-density lipoprotein cholesterol, negative outcomes, such as gastrointestinal adverse effects and severe hypoglycaemia, should also be considered in the use of metformin for T1D patients.

Efficacy of dapagliflozin as an adjunct therapy in patients with inadequately controlled type 1 diabetes mellitus

INTRODUCTION

There is a clear unmet clinical need in people with Type 1 diabetes (T1DM) considering present day insulin therapy. New insulin analogues and novel technologies allowing more tailored insulin administration have improved the quality of life of people with T1DM, but issues like hypoglycemia, weight gain and variability in glucose profiles remain problematic. Areas covered: In this review, the clinical efficacy, safety and tolerability of dapagliflozin, a sodium-glucose cotransporter type 2 inhibitor, in type 1 diabetes (T1DM) is described based on a review of phase 2 and 3 studies to date. Expert opinion: Dapagliflozin has shown promising results as an adjunct therapy in T1DM, resulting in better glucose control, weight loss and lower blood pressure. No increase in hypoglycemia risk, in particular severe hypoglycemia, was observed, but, in comparison with reports in Type 2 diabetes (T2DM), genital infections were more prevalent. Dapagliflozin use was accompanied with decreases in insulin doses, but, to date, only a low risk of diabetic ketoacidosis (DKA) was reported. However, caution is needed when interpreting this data, arising from well controlled clinical trials, with intensive education programs around ketone measurements and DKA prevention. Further studies will need to establish how high the DKA risk is and how to mitigate this in a real-world setting.

Novel blood glucose lowering therapies for managing type 1 diabetes in paediatric patients

INTRODUCTION

Therapy for type 1 diabetes (T1D) is mainly restricted to insulin treatment. The management of paediatric patients with T1D should tackle not only glucose control, but also insulin resistance, beta-cell preservation, quality of life and cardiovascular disease risk factors, which are increasingly recognized to occur in adolescents with T1D.

AREAS COVERED

This review examines the recently published literature from PubMed on non-insulin agents for the management of T1D in paediatric patients.

EXPERT OPINION

Few paediatric patients with T1D are achieving their metabolic targets. Current data support the need for new strategies and the consideration of additional therapies that not only may help patients, their families and their physicians to meet HbA1c targets, but also may preserve residual islet mass and good quality of life and prevent microvascular and macrovascular complications, thereby, reducing hypoglycaemic episodes. Non-insulin adjunctive therapies may improve not only glucose control, but also insulin sensitivity, in addition to preserving beta-cell function in T1D patients. Thus, more studies are required to define the potential role of these therapies in the management of paediatric patients.

A Review of Insulin Resistance in Type 1 Diabetes: Is There a Place for Adjunctive Metformin?

There is a rising trend of overweight and obesity among individuals with type 1 diabetes. This is often associated with insulin resistance, increased insulin dose requirements and poor glycemic control. Insulin resistance is also seen during puberty and is strongly related to increased risk of cardiovascular disease. The role of metformin as an adjunct to ongoing intensive insulin therapy in type 1 diabetics has been evaluated in several randomized trials, including the recently concluded T1D Exchange Network trial in adolescents and the REMOVAL trial in adults. Metformin reduces the insulin dose requirement, insulin-induced weight gain, and total and LDL cholesterol, but results in an increased risk of gastrointestinal adverse effects and a minor increase in the risk of hypoglycemia. In addition, metformin has been shown to reduce maximal carotid intima media thickness and therefore may extend cardioprotective benefits in type 1 diabetes. The role of metformin as adjunctive therapy in type 1 diabetes needs to be explored further in outcome trials.

Epigenetic regulation in B-cell maturation and its dysregulation in autoimmunity

B cells have a critical role in the initiation and acceleration of autoimmune diseases, especially those mediated by autoantibodies. In the peripheral lymphoid system, mature B cells are activated by self or/and foreign antigens and signals from helper T cells for differentiating into either memory B cells or antibody-producing plasma cells. Accumulating evidence has shown that epigenetic regulations modulate somatic hypermutation and class switch DNA recombination during B-cell activation and differentiation. Any abnormalities in these complex regulatory processes may contribute to aberrant antibody production, resulting in autoimmune pathogenesis such as systemic lupus erythematosus. Newly generated knowledge from advanced modern technologies such as next-generation sequencing, single-cell sequencing and DNA methylation sequencing has enabled us to better understand B-cell biology and its role in autoimmune development. Thus this review aims to summarize current research progress in epigenetic modifications contributing to B-cell activation and differentiation, especially under autoimmune conditions such as lupus, rheumatoid arthritis and type 1 diabetes.

Modifiable Risk Factors for Cardiovascular Disease in Children with Type 1 Diabetes: Can Early Intervention Prevent Future Cardiovascular Events?

PURPOSE OF REVIEW

Patients with type 1 diabetes have increased risk for cardiovascular disease. The purpose of this review is to examine the following: i) current evidence for subclinical cardiovascular disease (CVD) in children with type 1 diabetes (T1DM) ii) known modifiable risk factors for CVD and their relationship to subclinical CVD in this population iii) studies that have addressed these risk factors in order to improve CVD outcomes in children with T1DM RECENT FINDINGS: Subclinical CVD presents in children as increased carotid intima-media thickness, increased arterial stiffness, and endothelial and myocardial dysfunction. Modifiable risk factors for CVD include hyperglycemia, hyperlipidemia, obesity, hypertension, depression, and autonomic dysfunction. Very few randomized controlled studies have been done in children with T1DM to examine how modification of these risk factors can affect their CVD. Children with T1DM have subclinical CVD and multiple modifiable risk factors for CVD. More research is needed to define how modification of these factors affects the progression of CVD.

AMPK as a Therapeutic Target for Treating Metabolic Diseases

The AMP-activated protein kinase (AMPK) is a central regulator of multiple metabolic pathways and may have therapeutic importance for treating obesity, insulin resistance, type 2 diabetes (T2D), non-alcoholic fatty liver disease (NAFLD), and cardiovascular disease (CVD). Given the ubiquitous expression of AMPK, it has been a challenge to evaluate which tissue types may be most beneficially poised for mediating the positive metabolic effects of AMPK-centered treatments. In this review we evaluate the metabolic phenotypes of transgenic mouse models in which AMPK expression and function have been manipulated, and the impact this has on controlling lipid metabolism, glucose homeostasis, and inflammation. This information may be useful for guiding the development of AMPK-targeted therapeutics to treat chronic metabolic diseases.

Pharmacotherapy options for pediatric diabetes

PURPOSE OF REVIEW

Type 1 diabetes (T1D) and type 2 diabetes (T2D) are frequent conditions during childhood and adolescence. The present review offers an update on current available treatment strategies for T1D and T2D approved for use in children and adolescents.

RECENT FINDINGS

Insulin remains the main and essential therapeutic strategy in youth with T1D. A second generation of insulin analogues is being evaluated and could help in improving glycemic control. Over the last decades advances in technology have allowed the implementation of insulin pump therapy and continuous glucose monitoring, and are now leading the way towards the development of an artificial pancreas or closed loop system.Treatment of T2D is based on lifestyle interventions and metformin as the first-line drug to be used. Little evidence is available for other oral hypoglycemic drugs, currently used in adults.

SUMMARY

Although much progress has been made in the field of diabetes management, there are still several unmet goals. One of the main issues is to develop a system allowing more physiological insulin coverage. For both T1D and T2D, there is a strong need of new drugs to be used alone or in combination, mainly in patients struggling to achieve good glycemic control.

Epigenetics and type 1 diabetes: mechanisms and translational applications

Type 1 diabetes (T1D) is an irreversible degenerative disease with severe complications such as heart disease, nephropathy, neuropathy, and retinopathy. Although exogenous insulin administration is a life-saving therapy, it does not cure the disease. This review addresses the epigenetic mechanisms responsible for the development of T1D and discusses epigenetic-based strategies for prevention and treatment of the disease. We describe novel epigenetic biomarkers for the identification of susceptible individuals and the establishment of innovative therapies with epidrugs and cell therapy to regenerate the lost β-cells. Despite the wealth of promising data regarding the potential benefits of epigenetic tools to reduce the burden of T1D, clinical trials are still very few, and this issue needs to be resolved in the near future.