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Watanabe H, Asahara SI, Son J, McKimpson WM, de Cabo R, Accili D. Cyb5r3 activation rescues secondary failure to sulfonylurea but not β-cell dedifferentiation. PLoS One 2024; 19:e0297555. [PMID: 38335173 PMCID: PMC10857566 DOI: 10.1371/journal.pone.0297555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 01/09/2024] [Indexed: 02/12/2024] Open
Abstract
Diabetes mellitus is characterized by insulin resistance and β-cell failure. The latter involves impaired insulin secretion and β-cell dedifferentiation. Sulfonylurea (SU) is used to improve insulin secretion in diabetes, but it suffers from secondary failure. The relationship between SU secondary failure and β-cell dedifferentiation has not been examined. Using a model of SU secondary failure, we have previously shown that functional loss of oxidoreductase Cyb5r3 mediates effects of SU failure through interactions with glucokinase. Here we demonstrate that SU failure is associated with partial β-cell dedifferentiation. Cyb5r3 knockout mice show more pronounced β-cell dedifferentiation and glucose intolerance after chronic SU administration, high-fat diet feeding, and during aging. A Cyb5r3 activator improves impaired insulin secretion caused by chronic SU treatment, but not β-cell dedifferentiation. We conclude that chronic SU administration affects progression of β-cell dedifferentiation and that Cyb5r3 activation reverses secondary failure to SU without restoring β-cell dedifferentiation.
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Affiliation(s)
- Hitoshi Watanabe
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
- Naomi Berrie Diabetes Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
| | - Shun-ichiro Asahara
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
- Naomi Berrie Diabetes Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Jinsook Son
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
- Naomi Berrie Diabetes Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
| | - Wendy M. McKimpson
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
- Naomi Berrie Diabetes Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
| | - Rafael de Cabo
- Translational Gerontology Branch, National Institute on Aging, National Institutes of Health, Baltimore, Maryland, United States of America
| | - Domenico Accili
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
- Naomi Berrie Diabetes Center, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, United States of America
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Dutta D, Kadian J, Maisnam I, Kumar A, Bhattacharya S, Sharma M. Efficacy and Safety of Novel Thiazolidinedione Rivoglitazone in Type-2 Diabetes a Meta-Analysis. Indian J Endocrinol Metab 2023; 27:286-295. [PMID: 37867986 PMCID: PMC10586552 DOI: 10.4103/ijem.ijem_17_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/11/2023] [Accepted: 03/24/2023] [Indexed: 10/24/2023] Open
Abstract
No meta-analysis has analyzed the safety and efficacy of rivoglitazone in type-2 diabetes (T2DM). We undertook this meta-analysis to address this knowledge gap. Electronic databases were searched for RCTs involving T2DM patients receiving rivoglitazone in the intervention arm, and placebo/active comparator in the control arm. The primary outcome was to evaluate changes in HbA1c. Secondary outcomes were to evaluate alterations in glucose, lipids, and adverse events. From initially screened 24 articles, data from 3 RCTs (3591 patients) that fulfilled all criteria was analzsed. HbA1c was significantly lower with standard-dose (1 mg/d) [MD-0.86% (95%CI:-1.11--0.61); P < 0.01; I2 = 87%] and high-dose (1.5-2 mg/d) [MD-0.97%(95%CI:-1.03--0.90); P < 0.01; I2 = 19%] rivoglitazone compared to placebo. When compared to pioglitazone (30-45 mg/d), HbA1c lowering was comparable with standard-dose [MD 0.05%(95%CI:-0.01 - 0.11); P = 0.08; I2 = 11%], but superior with high-dose [MD -0.11%(95%CI:-0.18- -0.04); P < 0.01; I2 = 0%] rivoglitazone. Triglycerides were significantly lower with standard-dose [MD-17.95 mg/dl (95%CI:-34.23--1.66); P = 0.03; I2 = 0%] and high-dose [MD-40.41 mg/dl (95%CI:-72.90- -7.93);P = 0.01;I2 = 71%] rivoglitazone compared to placebo. Adiponectin significantly improved with standard-dose [MD 7.94 ng/ml (95%CI: 5.48-10.39); P < 0.01;I2 = 98%] and high-dose [MD 13.82 ng/ml (95%CI: 8.16-19.48); P < 0.01; I2 = 100%] rivoglitazone compared to placebo. hsCRP was significantly lower with standard-dose [MD -1.00 mg/L (95% CI: -1.20 - -0.80); P < 0.01; I2 = 6%] and high-dose [MD -1.50 mg/L (95%CI:-1.59- -1.40); P < 0.01; I2 = 0%] rivoglitazone compared to placebo. Treatment-emergent adverse events with standard-dose [Risk ratio (RR) 1.16 (95%CI: 0.84 -1.60); P = 0.38; I2 = 0%] and high-dose [RR1.34 (95%CI: 0.99-1.83); P = 0.06; I2 = 0%] rivoglitazone was comparable to placebo. Severe adverse events with standard-dose [RR1.88 (95%CI: 0.69-5.12);P = 0.22;I2 = 0%] and high-dose [RR 1.27 (95% CI: 0.45 - 3.59); P = 0.68; I2 = 0%] rivoglitazone was comparable to placebo. This meta-analysis highlights the good glycaemic efficacy and safety of both standard and high-dose rivoglitazone, and appears to be better than lobeglitazone in T2DM.
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Affiliation(s)
- Deep Dutta
- Department of Endocrinology, CEDAR Superspeciality Healthcare, Dwarka, New Delhi, India
| | - Jyoti Kadian
- Department of Medicine, Kalpana Chawla Government Medical College, Karnal, Haryana, India
| | - Indira Maisnam
- Department of Endocrinology, Institute of Post-graduate Medical Education and Research (IPGMER), Kolkata, West Bengal, India
| | - Ashok Kumar
- Department of Endocrinology, CEDAR Superspeciality Healthcare, Panipat, Haryana, India
| | | | - Meha Sharma
- Department of Rheumatology, CEDAR Superspeciality Healthcare, Dwarka, New Delhi, India
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Dutta D, Bhattacharya S, Kumar M, Datta PK, Mohindra R, Sharma M. Efficacy and safety of novel thiazolidinedione lobeglitazone for managing type-2 diabetes a meta-analysis. Diabetes Metab Syndr 2023; 17:102697. [PMID: 36580702 DOI: 10.1016/j.dsx.2022.102697] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/15/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS No meta-analysis has analysed the safety and efficacy of lobeglitazone in type-2 diabetes (T2DM). We undertook this meta-analysis to address this knowledge-gap. METHODS Electronic databases were searched for RCTs involving type-2 diabetes patients receiving lobeglitazone in intervention arm, and placebo/active comparator in control arm. Primary outcome was to evaluate changes in HbA1c. Secondary outcomes were to evaluate alterations in glucose, lipids and adverse events. RESULTS From initially screened 65 articles, data from 4 RCTs (828 patients) which fulfilled all criteria was analysed. Over 24 weeks, when compared to sitagliptin 100 mg/d and half maximal pioglitazone dose (15 mg/d), lobeglitazone 0.5 mg/day had comparable impact on HbA1c [MD 0.03% (95%CI: 0.11-0.17); P = 0.65; I2 = 0%], fasting glucose [MD 1.47 mg/dl (95%CI: 4.66-7.60); P = 0.64; I2 = 0%], triglycerides [MD-9.96 mg/dl (95%CI: 43.55-23.62); P = 0.56; I2 = 81%], LDL-cholesterol [MD0.74 mg/dl (95%CI: 4.60-6.09); P = 0.79; I2 = 0%] and HDL-cholesterol [MD1.55 mg/dl (95%CI: 3.72-6.82); P = 0.56]. Occurrence of treatment-emergent adverse events (AEs) [RR 1.07 (95% CI:0.78-1.47); P = 0.67; I2 = 0%] and severe AEs [RR 1.05(95%CI: 0.42-2.65); P = 0.91; I2 = 0%] were similar. Edema and weight gain were significantly higher with lobeglitazone compared to controls [RR 2.58 (95%CI: 1.08-6.17); P = 0.03; I2 = 0%]. Lobeglitazone 0.5 mg/d compared to half-maximal pioglitazone (15 mg/d), had similar edema and weight gain [RR 1.65 95% CI: 0.78-1.47)]. BMD percent changes at neck of femur was comparable in both groups [MD 0.07% (95%CI: 0.19-0.33); P = 0.60; I2 = 91%]. Low dose lobeglitazone (0.25 mg/d) was inferior to high dose lobeglitazone (0.5 mg/d) with regards to glycaemic efficacy with advantage of lower weight gain and edema. CONCLUSION The current evidence makes lobeglitazone unlikely to replace pioglitazone as the preferred thiazolidinedione in T2DM.
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Affiliation(s)
- Deep Dutta
- Department of Endocrinology, CEDAR Superspeciality Healthcare, Dwarka, New Delhi, India.
| | | | - Manoj Kumar
- Department of Endocrinology, CEDAR Superspeciality Healthcare, Zirakpur, Punjab, India.
| | - Priyankar K Datta
- Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences, New Delhi, India.
| | - Ritin Mohindra
- Department of Medicine, Post-graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Meha Sharma
- Department of Rheumatology, CEDAR Superspeciality Healthcare, Dwarka, New Delhi, India.
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Bae J, Park T, Kim H, Lee M, Cha BS. Lobeglitazone: A Novel Thiazolidinedione for the Management of Type 2 Diabetes Mellitus. Diabetes Metab J 2021; 45:326-336. [PMID: 33866775 PMCID: PMC8164939 DOI: 10.4093/dmj.2020.0272] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/23/2021] [Indexed: 12/30/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is characterized by insulin resistance and β-cell dysfunction. Among available oral antidiabetic agents, only the thiazolidinediones (TZDs) primarily target insulin resistance. TZDs improve insulin sensitivity by activating peroxisome proliferator-activated receptor γ. Rosiglitazone and pioglitazone have been used widely for T2DM treatment due to their potent glycemic efficacy and low risk of hypoglycemia. However, their use has decreased because of side effects and safety issues, such as cardiovascular concerns and bladder cancer. Lobeglitazone (Chong Kun Dang Pharmaceutical Corporation), a novel TZD, was developed to meet the demands for an effective and safe TZD. Lobeglitazone shows similar glycemic efficacy to pioglitazone, with a lower effective dose, and favorable safety results. It also showed pleiotropic effects in preclinical and clinical studies. In this article, we summarize the pharmacologic, pharmacokinetic, and clinical characteristics of lobeglitazone.
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Affiliation(s)
- Jaehyun Bae
- Division of Endocrinology and Metabolism, Department of Internal Medicine, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Taegyun Park
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Korea
| | - Hyeyoung Kim
- Medical information and Pharmacovigilance Team, CKD Pharmaceutical Corp., Seoul, Korea
| | - Minyoung Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Bong-Soo Cha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Corresponding author: Bong-Soo Cha https://orcid.org/0000-0003-0542-2854 Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea E-mail:
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Chu CH, Hsu CC, Lin SY, Chuang LM, Liu JS, Tu ST. Trends in antidiabetic medical treatment from 2005 to 2014 in Taiwan. J Formos Med Assoc 2019; 118 Suppl 2:S74-S82. [PMID: 31248659 DOI: 10.1016/j.jfma.2019.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/05/2019] [Accepted: 06/03/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND/PURPOSE Several new antidiabetic drugs have been introduced in Taiwan. However, the trends in antidiabetic treatment remain unexamined. METHODS We studied data from the Taiwan National Health Insurance Database to identify outpatient prescriptions for antidiabetic drugs from 2005 to 2014. The patterns in antidiabetic treatment and the number of different classes of antidiabetic drugs were analyzed. The proportions of prescriptions of antidiabetic monotherapy, combination therapy, or insulin therapy were further analyzed. RESULTS The total and mean prescriptions gradually increased during the study period. Prescription of oral antidiabetic drugs (OADs) only or insulin-only therapy decreased slightly. Prescriptions of monotherapy and dual therapy decreased, whereas those of triple or higher order combinations increased. Prescriptions of sulfonylureas (SUs) decreased, whereas those of metformin and dipeptidyl peptidease-4 (DPP4) inhibitors increased. Insulin prescriptions increased but accounted for only 13.07% of prescriptions in 2014. Among monotherapy prescriptions, SU prescriptions decreased, but metformin and DPP4 inhibitor prescriptions increased. Among dual OAD prescriptions, those including SUs decreased, and those of metformin and DPP4 inhibitors increased. Although prescriptions of the metformin-SU combination decreased, they remained the most common among all dual OAD prescriptions, followed by the metformin-DPP4 inhibitor combination. Prescriptions of human insulin decreased and those of insulin analogs increased considerably; those of basal insulin increased, and those of mixed insulin decreased. However, mixed insulin was prescribed more than basal-bolus insulin. CONCLUSION Antidiabetic treatment has become complex in Taiwan. Although combination therapy would become the major treatment strategy gradually, the underuse of insulin therapy must improve.
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Affiliation(s)
- Chih-Hsun Chu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Nursing, Fooyin University, Kaohsiung, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Shih-Yi Lin
- Center for Geriatrics and Gerontology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Lee-Ming Chuang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Graduate Institute of Preventive Medicine, National Taiwan University School of Public Health, Taipei, Taiwan
| | - Jia-Sin Liu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Shih-Te Tu
- Section of Endocrinology and Metabolism, Department of Medicine, Changhua Christian Hospital, Changhua, Taiwan.
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Bae J, Kim G, Lee YH, Lee BW, Kang ES, Cha BS. Differential Effects of Thiazolidinediones and Dipeptidyl Peptidase-4 Inhibitors on Insulin Resistance and β-Cell Function in Type 2 Diabetes Mellitus: A Propensity Score-Matched Analysis. Diabetes Ther 2019; 10:149-158. [PMID: 30506494 PMCID: PMC6349276 DOI: 10.1007/s13300-018-0541-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Comparisons of the glycemic durability between thiazolidinediones (TZDs) and dipeptidyl peptidase-4 (DPP-4) inhibitors remain insufficient. This study aimed to find clues for the differences in glycemic durability between TZDs and DPP-4 inhibitors by comparing the insulin resistance and β-cell function among patients using these agents. METHODS A total of 241 patients with type 2 diabetes mellitus (T2DM) treated with either pioglitazone (a TZD) or DPP-4 inhibitors as combination therapy with metformin for at least 1 year were analyzed. A propensity score based on the patients' baseline characteristics and glycated hemoglobin (HbA1c) was used to match them. Indices for insulin resistance and secretory function of β-cells, namely the homeostasis model assessment of insulin resistance (HOMA-IR) or β-cells (HOMA-β), were calculated and compared. Multiple regression analysis was performed to find the independent variables correlated with β-cell function or insulin resistance. RESULTS Evaluation of the data from 168 matched patients with T2DM showed that TZD users had significantly better insulin sensitivity compared with DPP-4 inhibitor users (HOMA-IR 2.3 ± 1.9 vs. 3.5 ± 3.2, p = 0.003). Conversely, DPP-4 inhibitor users secreted more insulin than TZD users (HOMA-β 45.7 ± 31.6 vs. 61.4 ± 49.5, p = 0.016). Multiple linear regression analysis showed that these agents were independently associated with both insulin resistance and β-cell function. CONCLUSION TZD users showed significantly better insulin sensitivity, whereas DPP-4 inhibitor users secreted more insulin from β-cells under similar glycemic control.
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Affiliation(s)
- Jaehyun Bae
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gyuri Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yong-Ho Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung-Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Seok Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Bong-Soo Cha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Tamaki Y, Maema K, Kakara M, Fukae M, Kinoshita R, Kashihara Y, Muraki S, Hirota T, Ieiri I. Characterization of changes in HbA1c in patients with and without secondary failure after metformin treatments by a population pharmacodynamic analysis using mixture models. Drug Metab Pharmacokinet 2018; 33:264-269. [PMID: 30360949 DOI: 10.1016/j.dmpk.2018.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 07/31/2018] [Accepted: 08/06/2018] [Indexed: 10/28/2022]
Abstract
The objective of the present study was to develop a population pharmacodynamic (PPD) model to describe the glycated hemoglobin (HbA1c)-lowering effects of metformin in type 2 diabetes mellitus patients with and without secondary failure and to characterize changes in HbA1c levels in the two subpopulations using a mixture model. Information on patients was collected retrospectively from electronic medical records. In this study, the mixture model was used to characterize the bimodal effects of metformin. A PPD analysis was performed using NONMEM 7.3.0. A physiological indirect response model, based on 829 HbA1c levels of 69 patients, described the time course for the HbA1c-lowering effects of metformin. Evidence for the different effectiveness of metformin subpopulations was provided using the mixture model. In the final PPD model, the inhibition effect was constant over a study duration in a patient subpopulation without secondary failure. In contrast, the inhibition effect decreased as a function of time after start of metformin treatment in a subpopulation with secondary failure. These results indicated that HbA1c improvements appeared to deteriorate over time in patients with secondary failure. In a PPD analysis of metformin, it was possible to assign patients with secondary failure using the mixture model.
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Affiliation(s)
- Yoko Tamaki
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Kunio Maema
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan; Yame General Hospital, Fukuoka, Japan
| | - Makoto Kakara
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Masato Fukae
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryoko Kinoshita
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Yushi Kashihara
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Shota Muraki
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeshi Hirota
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Ichiro Ieiri
- Department of Clinical Pharmacokinetics, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan.
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8
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Del Prato S, Chilton R. Practical strategies for improving outcomes in T2DM: The potential role of pioglitazone and DPP4 inhibitors. Diabetes Obes Metab 2018; 20:786-799. [PMID: 29171700 PMCID: PMC5887932 DOI: 10.1111/dom.13169] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/30/2017] [Accepted: 11/19/2017] [Indexed: 12/20/2022]
Abstract
T2DM is a complex disease underlined by multiple pathogenic defects responsible for the development and progression of hyperglycaemia. Each of these factors can now be tackled in a more targeted manner thanks to glucose-lowering drugs that have been made available in the past 2 to 3 decades. Recognition of the multiplicity of the mechanisms underlying hyperglycaemia calls for treatments that address more than 1 of these mechanisms, with more emphasis placed on the earlier use of combination therapies. Although chronic hyperglycaemia contributes to and amplifies cardiovascular risk, several trials have failed to show a marked effect from intensive glycaemic control. During the past 10 years, the effect of specific glucose-lowering agents on cardiovascular risk has been explored with dedicated trials. Overall, the cardiovascular safety of the new glucose-lowering agents has been proven with some of the trials summarized in this review, showing significant reduction of cardiovascular risk. Against this background, pioglitazone, in addition to exerting a sustained glucose-lowering effect, also has ancillary metabolic actions of potential interest in addressing the cardiovascular risk of T2DM, such as preservation of beta-cell mass and function. As such, it seems a logical agent to combine with other oral anti-hyperglycaemic agents, including dipeptidyl peptidase-4 inhibitors (DPP4i). DPP4i, which may also have a potential to preserve beta-cell function, is available as a fixed-dose combination with pioglitazone, and could, potentially, attenuate some of the side effects of pioglitazone, particularly if a lower dose of the thiazolidinedione is used. This review critically discusses the potential for early combination of pioglitazone and DPP4i.
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Affiliation(s)
- Stefano Del Prato
- Section of Metabolic Diseases and Diabetes, Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | - Robert Chilton
- Division of CardiologyUniversity of Texas Health Science Center at San Antonio and South Texas Veterans Health Care SystemSan AntonioTexas
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Ishida E, Kim-Muller JY, Accili D. Pair Feeding, but Not Insulin, Phloridzin, or Rosiglitazone Treatment, Curtails Markers of β-Cell Dedifferentiation in db/db Mice. Diabetes 2017; 66:2092-2101. [PMID: 28506962 PMCID: PMC5521857 DOI: 10.2337/db16-1213] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 05/02/2017] [Indexed: 12/31/2022]
Abstract
β-Cell failure is a hallmark of type 2 diabetes. Among several cellular biological mechanisms of cellular dysfunction, we and others have recently proposed that dedifferentiation of β-cells can explain the slowly progressive onset and partial reversibility of β-cell failure. Accordingly, we provided evidence of such processes in humans and experimental animal models of insulin-resistant diabetes. In this study, we asked whether β-cell dedifferentiation can be prevented with diet or pharmacological treatment of diabetes. db/db mice, a widely used model of insulin-resistant diabetes and obesity, were either pair fed or treated with the Sglt inhibitor phloridzin, the insulin-sensitizer rosiglitazone, or insulin. All treatments were equally efficacious in reducing plasma glucose levels. Pair feeding and phloridzin also resulted in significant weight loss. However, pair feeding among the four treatments resulted in a reduction of β-cell dedifferentiation, as assessed by Foxo1 and Aldh1a3 immunohistochemistry. The effect of diet to partly restore β-cell function is consistent with data in human diabetes and provides another potential mechanism by which lifestyle changes act as an effective intervention against diabetes progression.
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Affiliation(s)
- Emi Ishida
- Department of Medicine and Naomi Berrie Diabetes Center, Columbia University, New York, New York
| | - Ja Young Kim-Muller
- Department of Medicine and Naomi Berrie Diabetes Center, Columbia University, New York, New York
| | - Domenico Accili
- Department of Medicine and Naomi Berrie Diabetes Center, Columbia University, New York, New York
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Abdul-Ghani M, Migahid O, Megahed A, DeFronzo RA, Zirie M, Jayyousi A. Efficacy of Exenatide Plus Pioglitazone Vs Basal/Bolus Insulin in T2DM Patients With Very High HbA1c. J Clin Endocrinol Metab 2017; 102:2162-2170. [PMID: 28324038 DOI: 10.1210/jc.2016-3423] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/27/2017] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To examine the efficacy and safety of combination therapy with exenatide plus pioglitazone vs basal/bolus insulin in patients with poorly controlled type 2 diabetes mellitus (T2DM) with very high hemoglobin A1c (HbA1c) (>10%) receiving sulfonylurea plus metformin and with a long duration of disease. DESIGN AND PARTICIPANTS Participants (n = 101) in the Qatar Study with very poor glycemic control (HbA1c >10%) and a long duration of diabetes (10.9 years) receiving maximum/near-maximum doses of sulfonylurea plus metformin were randomly assigned to receive pioglitazone plus weekly exenatide (combination therapy), or basal plus prandial insulin (insulin therapy), to maintain HbA1c <7.0%. RESULTS Baseline HbA1c was 11.5% ± 0.2% and 11.2% ± 0.2% (P = not significant) in combination therapy and insulin therapy groups, respectively. At 6 months, combination therapy caused a robust decrease in HbA1c to 6.7% ± 0.1% (∆ = -4.8%) compared with 7.4% ± 0.1% (∆ = -3.8%) in subjects receiving insulin therapy. Combination therapy was effective in lowering the HbA1c independent of sex, ethnicity, or body mass index. Subjects in the insulin therapy group experienced significantly greater weight gain and a 2.5-fold higher rate of hypoglycemia compared with patients receiving combination therapy. CONCLUSION Exenatide/pioglitazone combination therapy is an effective and safe therapeutic option in patients with poorly controlled T2DM receiving metformin plus sulfonylurea with very high HbA1c (>10%).
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Affiliation(s)
- Muhammad Abdul-Ghani
- Diabetes Research, Academic Health System, Hamad General Hospital, Doha, Qatar
- Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229
| | - Osama Migahid
- Diabetes Research, Academic Health System, Hamad General Hospital, Doha, Qatar
| | - Ayman Megahed
- Diabetes Research, Academic Health System, Hamad General Hospital, Doha, Qatar
| | - Ralph A DeFronzo
- Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229
| | - Mahmoud Zirie
- Diabetes Research, Academic Health System, Hamad General Hospital, Doha, Qatar
| | - Amin Jayyousi
- Diabetes Research, Academic Health System, Hamad General Hospital, Doha, Qatar
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Abdul-Ghani M, Migahid O, Megahed A, Adams J, Triplitt C, DeFronzo RA, Zirie M, Jayyousi A. Combination Therapy With Exenatide Plus Pioglitazone Versus Basal/Bolus Insulin in Patients With Poorly Controlled Type 2 Diabetes on Sulfonylurea Plus Metformin: The Qatar Study. Diabetes Care 2017; 40:325-331. [PMID: 28096223 PMCID: PMC5864032 DOI: 10.2337/dc16-1738] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 12/19/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The Qatar Study was designed to examine the efficacy of combination therapy with exenatide plus pioglitazone versus basal/bolus insulin in patients with long-standing poorly controlled type 2 diabetes mellitus (T2DM) on metformin plus a sulfonylurea. RESEARCH DESIGN AND METHODS The study randomized 231 patients with poorly controlled (HbA1c >7.5%, 58 mmol/mol) T2DM on a sulfonylurea plus metformin to receive 1) pioglitazone plus weekly exenatide (combination therapy) or 2) basal plus prandial insulin (insulin therapy) to maintain HbA1c <7.0% (53 mmol/mol). RESULTS After a mean follow-up of 12 months, combination therapy caused a robust decrease in HbA1c from 10.0 ± 0.6% (86 ± 5.2 mmol/mol) at baseline to 6.1 ± 0.1% (43 ± 0.7 mmol/mol) compared with 7.1 ± 0.1% (54 ± 0.8 mmol/mol) in subjects receiving insulin therapy. Combination therapy was effective in lowering the HbA1c independent of sex, ethnicity, BMI, or baseline HbA1c. Subjects in the insulin therapy group experienced significantly greater weight gain and a threefold higher rate of hypoglycemia than patients in the combination therapy group. CONCLUSIONS Combination exenatide/pioglitazone therapy is a very effective and safe therapeutic option in patients with long-standing poorly controlled T2DM on metformin plus a sulfonylurea.
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Affiliation(s)
- Muhammad Abdul-Ghani
- Diabetes Research, Academic Health System, Hamad General Hospital, Doha, Qatar .,Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Osama Migahid
- Diabetes Research, Academic Health System, Hamad General Hospital, Doha, Qatar
| | - Ayman Megahed
- Diabetes Research, Academic Health System, Hamad General Hospital, Doha, Qatar
| | - John Adams
- Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Curtis Triplitt
- Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Ralph A DeFronzo
- Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Mahmoud Zirie
- Diabetes Research, Academic Health System, Hamad General Hospital, Doha, Qatar
| | - Amin Jayyousi
- Diabetes Research, Academic Health System, Hamad General Hospital, Doha, Qatar
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12
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Stringer F, DeJongh J, Enya K, Koumura E, Danhof M, Kaku K. Evaluation of the long-term durability and glycemic control of fasting plasma glucose and glycosylated hemoglobin for pioglitazone in Japanese patients with type 2 diabetes. Diabetes Technol Ther 2015; 17:215-23. [PMID: 25531677 PMCID: PMC4346657 DOI: 10.1089/dia.2014.0222] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study applied a pharmacodynamic model-based approach to evaluate the long-term durability and glycemic control of pioglitazone in comparison with other oral glucose-lowering drugs in Japanese type 2 diabetes mellitus (T2DM) patients. SUBJECTS AND METHODS Japanese T2DM patients were enrolled in a prospective, randomized, open-label, blinded-end point study and received pioglitazone with or without other oral glucose-lowering drugs (excluding another thiazolidinedione [TZD]) (n=293) or oral glucose-lowering drugs excluding TZD (n=294). Treatment was adjusted to achieve glycosylated hemoglobin (HbA1c) <6.9%, and samples for fasting plasma glucose (FPG) and HbA1c were collected over 2.5-4 years. A simultaneous cascading indirect response model structure was applied to describe the time course of FPG and HbA1c. HbA1c levels were described using both an FPG-dependent and an FPG-independent function. To account for titration, drug effects for both treatment groups were implemented using a time-dependent Emax model. RESULTS Pioglitazone was superior in both time to maximum effect and the magnitude of reduction achieved in FPG and HbA1c. A greater reduction in median FPG (-21 mg/dL vs. -9 mg/dL) was observed with pioglitazone (P<0.05). Maximum drug effect for FPG was predicted to occur earlier (11 months) for pioglitazone than for the control group (14 months). The simulated additional reduction in FPG and HbA1c achieved with pioglitazone was predicted to be maintained beyond the currently observed study duration. CONCLUSIONS Pioglitazone was found to result in improved glycemic control and durability compared with control treatment. This model-based approach enabled the quantification of differences in FPG and HbA1c for both treatment groups and simulation to evaluate longer-term durability on FPG and HbA1c.
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Affiliation(s)
| | - Joost DeJongh
- LAP&P Consultants BV, Leiden, The Netherlands
- Leiden-Academic Centre for Drug Research, Division of Pharmacology, Leiden, The Netherlands
| | - Kazuaki Enya
- Takeda Pharmaceutical Company Ltd., Osaka, Japan
| | | | - Meindert Danhof
- LAP&P Consultants BV, Leiden, The Netherlands
- Leiden-Academic Centre for Drug Research, Division of Pharmacology, Leiden, The Netherlands
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13
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Abdul-Ghani MA, Puckett C, Triplitt C, Maggs D, Adams J, Cersosimo E, DeFronzo RA. Initial combination therapy with metformin, pioglitazone and exenatide is more effective than sequential add-on therapy in subjects with new-onset diabetes. Results from the Efficacy and Durability of Initial Combination Therapy for Type 2 Diabetes (EDICT): a randomized trial. Diabetes Obes Metab 2015; 17:268-75. [PMID: 25425451 PMCID: PMC5577982 DOI: 10.1111/dom.12417] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/20/2014] [Accepted: 11/20/2014] [Indexed: 12/25/2022]
Abstract
AIM To test our hypothesis that initiating therapy with a combination of agents known to improve insulin secretion and insulin sensitivity in subjects with new-onset diabetes would produce greater, more durable reduction in glycated haemoglobin (HbA1c) levels, while avoiding hypoglycaemia and weight gain, compared with sequential addition of agents that lower plasma glucose but do not correct established pathophysiological abnormalities. METHODS Drug-naïve, recently diagnosed subjects with type 2 diabetes mellitus (T2DM) were randomized in an open-fashion design in a single-centre study to metformin/pioglitazone/exenatide (triple therapy; n = 106) or an escalating dose of metformin followed by sequential addition of sulfonylurea and glargine insulin (conventional therapy; n = 115) to maintain HbA1c levels at <6.5% for 2 years. RESULTS Participants receiving triple therapy experienced a significantly greater reduction in HbA1c level than those receiving conventional therapy (5.95 vs. 6.50%; p < 0.001). Despite lower HbA1c values, participants receiving triple therapy experienced a 7.5-fold lower rate of hypoglycaemia compared with participants receiving conventional therapy. Participants receiving triple therapy experienced a mean weight loss of 1.2 kg versus a mean weight gain of 4.1 kg (p < 0.01) in those receiving conventional therapy. CONCLUSION The results of this exploratory study show that combination therapy with metformin/pioglitazone/exenatide in patients with newly diagnosed T2DM is more effective and results in fewer hypoglycaemic events than sequential add-on therapy with metformin, sulfonylurea and then basal insulin.
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Affiliation(s)
- M A Abdul-Ghani
- Diabetes Division, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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14
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Schwartz S. Evidence-based practice use of incretin-based therapy in the natural history of diabetes. Postgrad Med 2014; 126:66-84. [PMID: 24918793 DOI: 10.3810/pgm.2014.05.2757] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The incretin class of anti-hyperglycemic agents, including glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-inhibitors, is an important addition to the therapeutic armamentarium for the management of appropriate patients with type 2 diabetes mellitus as an adjunct to diet and exercise and/or with the agents metformin, sulfonylureas, thiazolidinediones, or any combination thereof. More recently, US Food and Drug Administration (FDA)-approved indications for incretins were expanded to include use with basal insulin. This review article takes an evidence-based practice approach in discussing the importance of aggressive treatment for diabetes, the principles of incretin physiology and pathophysiology, use of glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors, and patient types and contexts where incretin therapy has been found beneficial, from metabolic syndrome to overt diabetes.
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Affiliation(s)
- Stanley Schwartz
- Affiliate, Main Line Health System, Ardmore, PA; Emeritus, Clinical Associate Professor of Medicine, University of Pennsylvania, Philadelphia, PA.
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15
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Cefalu WT, Buse JB, Del Prato S, Home PD, LeRoith D, Nauck MA, Raz I, Rosenstock J, Riddle MC. Beyond metformin: safety considerations in the decision-making process for selecting a second medication for type 2 diabetes management: reflections from a diabetes care editors' expert forum. Diabetes Care 2014; 37:2647-59. [PMID: 25147257 PMCID: PMC5169170 DOI: 10.2337/dc14-1395] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The trend toward personalized management of diabetes has focused attention on the differences among available pharmacological agents in terms of mechanisms of action, efficacy, and, most important, safety. Clinicians must select from these features to develop individualized therapy regimens. In June 2013, a nine-member Diabetes Care Editors' Expert Forum convened to review safety evidence for six major diabetes drug classes: insulin, sulfonylureas (SUs), thiazolidinediones (TZDs), glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, and sodium glucose cotransporter 2 inhibitors. This article, an outgrowth of the forum, summarizes well-delineated and theoretical safety concerns related to these drug classes, as well as the panelists' opinions regarding their best use in patients with type 2 diabetes. All of the options appear to have reasonably wide safety margins when used appropriately. Those about which we know the most-metformin, SUs, insulin, and perhaps now also TZDs-are efficacious in most patients and can be placed into a basic initial algorithm. However, these agents leave some clinical needs unmet. Selecting next steps is a more formidable process involving newer agents that are understood less well and for which there are unresolved questions regarding risk versus benefit in certain populations. Choosing a specific agent is not as important as implementing some form of early intervention and advancing rapidly to some form of combination therapy as needed. When all options are relatively safe given the benefits they confer, therapeutic decision making must rely on a personalized approach, taking into account patients' clinical circumstances, phenotype, pathophysiological defects, preferences, abilities, and costs.
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Affiliation(s)
- William T Cefalu
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA
| | - John B Buse
- University of North Carolina School of Medicine, Chapel Hill, NC
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa School of Medicine, Pisa, Italy
| | | | | | | | - Itamar Raz
- Diabetes Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Julio Rosenstock
- Dallas Diabetes and Endocrine Center at Medical City and University of Texas Southwestern Medical Center, Dallas, TX
| | - Matthew C Riddle
- Division of Endocrinology, Diabetes, and Clinical Nutrition, Oregon Health & Science University, Portland, OR
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16
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DeFronzo RA, Eldor R, Abdul-Ghani M. Pathophysiologic approach to therapy in patients with newly diagnosed type 2 diabetes. Diabetes Care 2013; 36 Suppl 2:S127-38. [PMID: 23882037 PMCID: PMC3920797 DOI: 10.2337/dcs13-2011] [Citation(s) in RCA: 194] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Ralph A DeFronzo
- Diabetes Division, University of Texas Health Science Center, San Antonio, Texas, USA.
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17
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Defronzo RA, Mehta RJ, Schnure JJ. Pleiotropic effects of thiazolidinediones: implications for the treatment of patients with type 2 diabetes mellitus. Hosp Pract (1995) 2013; 41:132-147. [PMID: 23680744 DOI: 10.3810/hp.2013.04.1062] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Thiazolidinediones (TZDs) are insulin-sensitizing antidiabetes agents that act through the peroxisome proliferator-activated receptor-γ to cause a durable improvement in glycemic control in patients with type 2 diabetes mellitus. Although less well recognized, TZDs also exert a protective effect on β-cell function. In addition to their beneficial effects on glucose homeostasis, TZDs-especially pioglitazone-exert a number of other pleiotropic effects that make them ideal agents as monotherapy or in combination with other oral agents, glucagon-like peptide-1 analogs, or insulin. Pioglitazone improves endothelial dysfunction, reduces blood pressure, corrects diabetic dyslipidemia, and reduces circulating levels of inflammatory cytokines and prothrombotic factors. Pioglitazone also redistributes fat and toxic lipid metabolites in muscle, liver, β cells, and arteries, and deposits the fat in subcutaneous adipocytes where it cannot exert its lipotoxic effects. Consistent with these antiatherogenic effects, pioglitazone reduced major adverse cardiac event endpoints (ie, mortality, myocardial infarction, and stroke) in the Prospective Pioglitazone Clinical Trial in Macrovascular Events and in a meta-analysis of all other published pioglitazone trials. Pioglitazone also mobilizes fat out of the liver, improving liver function and histologic abnormalities in patients with nonalcoholic fatty liver disease and nonalcoholic steatohepatitis. Pioglitazone also reduces proteinuria, all-cause mortality, and cardiovascular events in patients with type 2 diabetes mellitus with a reduced glomerular filtration rate. These benefits must be weighed against the side effects of the drug, including weight gain, fluid retention, atypical fractures, and, possibly, bladder cancer. When low doses of pioglitazone are used (eg, 7.5-30 mg/d) with gradual titration, and physician recognition of the potential side effects are applied, the risk-to-benefit ratio is very favorable. Despite having similar effects on glycemic control, pioglitazone and rosiglitazone appear to have different effects on cardiovascular outcomes. Rosiglitazone has been associated with an increased risk of myocardial infarction, and its use in the United States is restricted because of cardiovascular safety concerns.
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Affiliation(s)
- Ralph A Defronzo
- The University of Texas Health Science Center, San Antonio, TX 78229, USA.
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18
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Kumar A. Second line therapy: type 2 diabetic subjects failing on metformin GLP-1/DPP-IV inhibitors versus sulphonylurea/insulin: for GLP-1/DPP-IV inhibitors. Diabetes Metab Res Rev 2012; 28 Suppl 2:21-5. [PMID: 23280862 DOI: 10.1002/dmrr.2350] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Following diagnosis, type 2 diabetic subjects are invariably treated with life style modifications and metformin. However, majority of these subjects require addition of another therapeutic agent singly or in combination; with or without insulin within few months to few years. For several decades, sulphonylureas and insulin have been the second line agent of choice. Clinical practice guidelines also suggest a similar approach. Subsequently thiazolidinediones, alpha glucose inhibitors and other agents were added to therapeutic armamentarium. Unfortunately, none of these treatment options could address the issue of progressive decline in beta cell function. Furthermore, they are responsible for unacceptable incidence of hypoglycaemia, weight gain and other side effects related to individual agents. Type 2 diabetic subjects have great propensity to develop cardiovascular complications. Sulphonylureas, insulin and thiazolidinediones have all been associated with adverse cardiovascular outcomes in differing magnitude. It has been made mandatory by regulatory agencies to ensure cardiovascular safety of any new anti-diabetic agent. Glucagon Like Peptide-1(GLP-1)-based therapies have been able to address several of these issues. Incretin mimetics and Di Peptidyl Dipeptidase IV (DPP-IV) inhibitors cause glucose-dependent insulin secretion and glucagon suppression from beta and alpha cells of the pancreas respectively. They owe this property to their binding with G-Protein-coupled receptors leading to an increased amount of c-AMP. They do not cause beta cell exhaustion. On the contrary such agents prevent beta cell apoptosis. Clinical trials have established the superiority of incretin mimetics particularly liraglutide against comparators including glimepiride, rosiglitazone and insulin Glargine in terms of efficacy. Furthermore, they have shown evidence towards beta cell protection, significant weight loss, minimal hypoglycaemia and favourable impact on surrogate markers of cardiovascular outcomes. DPP-IV inhibitors have limited ability to achieve glycaemic targets. However, they are weight neutral, cause minimal hypoglycaemia and have some beneficial effect on beta cell function. Finally, they are very well tolerated.
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Affiliation(s)
- Ajay Kumar
- Diabetes Care & Research Centre, Patna, India.
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19
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Chang CH, Jiang YD, Chung CH, Ho LT, Chuang LM. National trends in anti-diabetic treatment in Taiwan, 2000-2009. J Formos Med Assoc 2012; 111:617-24. [PMID: 23217597 DOI: 10.1016/j.jfma.2012.09.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 09/03/2012] [Accepted: 09/06/2012] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND/PURPOSE The impact of the introduction of newer anti-diabetic agents on the treatment pattern in the booming diabetic population remains unclear. We examined the patterns and temporal trends of anti-diabetic drug use in Taiwan, with particular emphasis on combination therapy. METHODS We searched the Taiwan National Health Insurance Database during 2000-2009 to identify outpatient prescriptions of anti-diabetic drugs, including human insulins and insulin analogues, sulfonylureas, glinides, metformin, thiazolidinediones, alpha-glucosidase inhibitors, and dipeptidyl peptidase-4 inhibitors. Glucose-lowering treatments were classified according to pattern (oral agents only, insulins only, and oral agents and insulins combined) and a number of different classes of anti-diabetic drugs. Insulin therapy and combination therapy with two oral anti-diabetic drugs (OAD) were further classified according to individual drug combination patterns. RESULTS Although metformin remained the mainstay of anti-diabetic treatment, patients receiving combination therapy of oral glucose-lowering agents, either with or without insulin, significantly increased, from approximately 40% in 2000 to 60% in 2009, particularly in relation to the newer agents, including glinides, alpha-glucosidase inhibitors, and long-acting insulin analogues. Use of sulfonylureas and thiazolidinediones decreased substantially. For insulin therapy, the most commonly prescribed drugs were premix insulin analogues and basal insulin analogues, accounting for one-third of total insulin prescriptions in 2009. CONCLUSION We found an increasing complexity of anti-diabetic therapy during the past decade in Taiwan. Further studies are needed to evaluate whether this treatment pattern will lead to improved clinical outcomes in terms of cost-effectiveness.
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Affiliation(s)
- Chia-Hsuin Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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20
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Alogliptin-Pioglitazone Combination Therapy: A Rational Approach to Treating Type 2 Diabetes Mellitus. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s13556-012-0004-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Aicher TD, Boyd SA, McVean M, Celeste A. Novel therapeutics and targets for the treatment of diabetes. Expert Rev Clin Pharmacol 2012; 3:209-29. [PMID: 22111568 DOI: 10.1586/ecp.10.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The microvascular complications of insufficiently controlled diabetes (neuropathy, retinopathy and nephropathy) and the marked increased risk of macrovascular events (e.g., stroke and myocardial infarction) have a dire impact on society in both human and economic terms. In Type 1 diabetes total β-cell loss occurs. In Type 2 diabetes, partial β-cell loss occurs before diagnosis, and the progressive β-cell loss during the life of the patient increases the severity of the disease. In patients with diabetes, increased insulin resistance in the muscle and liver are key pathophysiologic defects. In addition, defects in metabolic processes in the fat, GI tract, brain, pancreatic α-cells and kidney are detrimental to the overall health of the patient. This review addresses novel therapies for these deficiencies in clinical and preclinical evaluation, emphasizing their potential to address glucose homeostasis, β-cell mass and function, and the comorbidities of cardiovascular disease and obesity.
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Affiliation(s)
- Thomas D Aicher
- Principal Research Investigator, Array BioPharma Inc., 3200 Walnut Street, Boulder, CO 80301, USA.
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22
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Düfer M, Noack K, Edalat A, Krippeit-Drews P, Drews G. Glitazones exert multiple effects on β-cell stimulus-secretion coupling. Mol Pharmacol 2012; 83:51-60. [PMID: 23024191 DOI: 10.1124/mol.112.081638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Earlier studies suggest that glitazones exert beneficial effects in patients with type 2 diabetes by directly affecting insulin secretion of β-cells, besides improving the effectiveness of insulin in peripheral tissues. The effects of glitazones on stimulus-secretion coupling (SSC) are poorly understood. We tested the influence of troglitazone and pioglitazone on different parameters of SSC, including insulin secretion (radioimmunoassay), cell membrane potential, various ion currents (patch-clamp), mitochondrial membrane potential (ΔΨ), and cytosolic Ca(2+) concentration (fluorescence). Troglitazone exerted stimulatory, inhibitory, or no effects on insulin secretion depending on the drug and glucose concentration. It depolarized the ΔΨ, thus lowering ATP production, which resulted in opening of ATP-dependent K(+) channels (K(ATP) channels) and reduced insulin secretion. However, it also exerted direct inhibitory effects on K(ATP) channels that can explain enhanced insulin secretion. Troglitazone also inhibited the currents through voltage-dependent Ca(2+) and K(+) channels. Pioglitazone was less effective than troglitazone on all parameters tested. The effects of both glitazones were markedly reduced in the presence of bovine serum albumin. Glitazones exert multiple actions on β-cell SSC that have to be considered as undesired side effects because the influence of these compounds on β-cells is not controllable. The final effect on insulin secretion depends on many parameters, including the actual glucose and drug concentration, protein binding of the drug, and the drug by itself. Troglitazone and pioglitazone differ in their influence on SSC. It can be assumed that the effects of pioglitazone on β-cells are negligible under in vivo conditions.
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Affiliation(s)
- Martina Düfer
- Institute of Pharmacy, Department of Pharmacology, University of Tübingen, Auf der Morgenstelle 8, D-72076 Tübingen, Germany
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Hakobyan L, Haaijer-Ruskamp FM, de Zeeuw D, Dobre D, Denig P. A review of methods used in assessing non-serious adverse drug events in observational studies among type 2 diabetes mellitus patients. Health Qual Life Outcomes 2011; 9:83. [PMID: 21958008 PMCID: PMC3198877 DOI: 10.1186/1477-7525-9-83] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 09/29/2011] [Indexed: 01/24/2023] Open
Abstract
Clinical drug trials are often conducted in selective patient populations, with relatively small numbers of patients, and a short duration of follow-up. Observational studies are therefore important for collecting additional information on adverse drug events (ADEs). Currently, there is no guidance regarding the methodology for measuring ADEs in such studies. Our aim was to evaluate whether the methodology used to assess non-serious ADEs in observational studies is adequate for detecting these ADEs, and for addressing limitations from clinical trials in patients with type 2 diabetes mellitus. We systematically searched MEDLINE and EMBASE for observational studies reporting non-serious ADEs (1999-2008). Methods to assess ADEs were classified as: 1) medical record review; 2) surveillance by health care professionals (HCP); 3) patient survey; 4) administrative data; 5) laboratory/clinical values; 6) not specified. We compared the range of ADEs identified, number and selection of patients included, and duration of follow-up. Out of 10,125 publications, 68 studies met our inclusion criteria. The most common methods were based on laboratory/clinical values (n = 25) and medical record review (n = 18). Solicited surveillance by HCP (n = 17) revealed the largest diversity of ADEs. Patient surveys (n = 15) focused mostly on hypoglycaemia and gastrointestinal ADEs, laboratory values based studies on hepatic and metabolic ADEs, and administrative database studies (n = 5) on cardiovascular ADEs. Four studies presented ADEs that were identified with the use of more than one method. The patient population was restricted to a lower risk population in 19% of the studies. Less than one third of the studies exceeded pre-approval regulatory requirements for sample size and duration of follow-up. We conclude that the current assessment of ADEs is hampered by the choice of methods. Many observational studies rely on methods that are inadequate for identifying all possible ADEs. Patient-reported outcomes and combinations of methods are underutilized. Furthermore, while observational studies often include unselective patient populations, many do not adequately address other limitations of pre-approval trials. This implies that these studies will not provide sufficient information about ADEs to clinicians and patients. Better protocols are needed on how to assess adverse drug events not only in clinical trials but also in observational studies.
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Affiliation(s)
- Liana Hakobyan
- Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Flora M Haaijer-Ruskamp
- Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, The Netherlands
- Graduate School of Medical Sciences, University of Groningen, Groningen, The Netherlands
| | - Dick de Zeeuw
- Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Daniela Dobre
- Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, The Netherlands
- Graduate School of Medical Sciences, University of Groningen, Groningen, The Netherlands
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Rodríguez A, Reviriego J, Karamanos V, del Cañizo FJ, Vlachogiannis N, Drossinos V. Management of cardiovascular risk factors with pioglitazone combination therapies in type 2 diabetes: an observational cohort study. Cardiovasc Diabetol 2011; 10:18. [PMID: 21314919 PMCID: PMC3042924 DOI: 10.1186/1475-2840-10-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 02/11/2011] [Indexed: 11/15/2022] Open
Abstract
Background Type 2 diabetes (T2D) is strongly associated with cardiovascular risk and requires medications that improve glycemic control and other cardiovascular risk factors. The authors aimed to assess the relative effectiveness of pioglitazone (Pio), metformin (Met) and any sulfonylurea (SU) combinations in non-insulin-treated T2D patients who were failing previous hypoglycemic therapy. Methods Over a 1-year period, two multicenter, open-labeled, controlled, 1-year, prospective, observational studies evaluated patients with T2D (n = 4585) from routine clinical practice in Spain and Greece with the same protocol. Patients were eligible if they had been prescribed Pio + SU, Pio + Met or SU + Met serving as a control cohort, once they had failed with previous therapy. Anthropometric measurements, lipid and glycemic profiles, blood pressure, and the proportions of patients at microvascular and macrovascular risk were assessed. Results All study treatment combinations rendered progressive 6-month and 12-month lipid, glycemic, and blood pressure improvements. Pio combinations, especially Pio + Met, were associated with increases in HDL-cholesterol and decreases in triglycerides and in the atherogenic index of plasma. The proportion of patients at high risk decreased after 12 months in all study cohorts. Minor weight changes (gain or loss) and no treatment-related fractures occurred during the study. The safety profile was good and proved similar among treatments, except for more hypoglycemic episodes in patients receiving SU and for the occurrence of edema in patients using Pio combinations. Serious cardiovascular events were rarely reported. Conclusions In patients with T2D failing prior hypoglycemic therapies, Pio combinations with SU or Met (especially Pio + Met) improved blood lipid and glycemic profiles, decreasing the proportion of patients with a high microvascular or macrovascular risk. The combination of Pio with SU or Met may therefore be recommended for T2D second-line therapy in the routine clinical practice, particularly in patients with dyslipidemia.
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Kim SW. Triple Combination Therapy Using Metformin, Thiazolidinedione, and a GLP-1 Analog or DPP-IV Inhibitor in Patients with Type 2 Diabetes Mellitus. KOREAN DIABETES JOURNAL 2010; 34:331-7. [PMID: 21246005 PMCID: PMC3021108 DOI: 10.4093/kdj.2010.34.6.331] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Although there is no HbA1c threshold for cardiovascular risk, the American Diabetic Association-recommended goal of HbA1c < 7.0% appears to be unacceptably high. To achieve an optimal HbA1c level goal of 6.0% or less, a high dosage of sulfonylureas and insulin would be required; the trade-off would be the common adverse effects of hypoglycemia and weight gain. In contrast, hypoglycemia is uncommon with insulin sensitizers and GLP-1 analogs, allowing the physician to titrate these drugs to maximum dosage to reduce HbA1c levels below 6.0% and they have been shown to preserve β-cell function. Lastly, weight gain is common with sulfonylurea and insulin therapy, whereas GLP-1 analogs induce weight loss and offset the weight gain associated with TZDs. A treatment paradigm shift is recommended in which combination therapy is initiated with diet/exercise, metformin (which has antiatherogenic effects and improves hepatic insulin sensitivity), a TZD (which improves insulin sensitivity and preserves β-cell function with proven durability), and a GLP-1 analog (which improves β, α-cell function and promotes weight loss) or a dipeptidyl peptidase IV inhibitor in patients with type 2 diabetes mellitus.
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Affiliation(s)
- Sun Woo Kim
- Diabetes Center, Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Pioglitazone is an oral antidiabetic agent that decreases insulin resistance in adipose tissue, liver and muscles. This action is mediated by its link to a nuclear receptor called peroxisome proliferator-activated receptor-gamma. By improving insulin sensitivity, hepatic glucose production decreases and glucose uptake increases in the peripheral tissues. Beyond these effects on glucose metabolism, pioglitazone has positive effects on lipid metabolism, blood pressure, endothelial function, adiponectin and C-reactive protein levels. These make pioglitazone treatment effective beyond glucose control. In this article, current evidence concerning pioglitazone in the treatment of Type 2 diabetes will be reviewed.
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Affiliation(s)
- Pedro de Pablos-Velasco
- Department of Endocrinology & Diabetes and Metabolism, Dr Negrin Hospital, Las Palmas University, Spain.
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Triplitt C, Cersosimo E, DeFronzo RA. Pioglitazone and alogliptin combination therapy in type 2 diabetes: a pathophysiologically sound treatment. Vasc Health Risk Manag 2010; 6:671-90. [PMID: 20859539 PMCID: PMC2941781 DOI: 10.2147/vhrm.s4852] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Indexed: 01/11/2023] Open
Abstract
Insulin resistance and islet (beta and alpha) cell dysfunction are major pathophysiologic abnormalities in type 2 diabetes mellitus (T2DM). Pioglitazone is a potent insulin sensitizer, improves pancreatic beta cell function and has been shown in several outcome trials to lower the risk of atherosclerotic and cardiovascular events. Glucagon-like peptide-1 deficiency/resistance contributes to islet cell dysfunction by impairing insulin secretion and increasing glucagon secretion. Dipeptidyl peptidase-4 (DPP-4) inhibitors improve pancreatic islet function by augmenting glucose-dependent insulin secretion and decreasing elevated plasma glucagon levels. Alogliptin is a new DPP-4 inhibitor that reduces glycosylated hemoglobin (HbA1c), is weight neutral, has an excellent safety profile, and can be used in combination with oral agents and insulin. Alogliptin has a low risk of hypoglycemia, and serious adverse events are uncommon. An alogliptin–pioglitazone combination is advantageous because it addresses both insulin resistance and islet dysfunction in T2DM. HbA1c reductions are significantly greater than with either monotherapy. This once-daily oral combination medication does not increase the risk of hypoglycemia, and tolerability and discontinuation rates do not differ significantly from either monotherapy. Importantly, measures of beta cell function and health are improved beyond that observed with either monotherapy, potentially improving durability of HbA1c reduction. The alogliptin–pioglitazone combination represents a pathophysiologically sound treatment of T2DM.
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Affiliation(s)
- Curtis Triplitt
- Diabetes Division, Department of Medicine, University of Texas, Health Science Center at San Antonio, San Antonio, Texas 78229-3900, USA
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Barnett AH. Avoiding hypoglycaemia while achieving good glycaemic control in type 2 diabetes through optimal use of oral agent therapy. Curr Med Res Opin 2010; 26:1333-42. [PMID: 20370379 DOI: 10.1185/03007991003738063] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Patients with type 2 diabetes appear to be at relatively low risk of severe hypoglycaemia and hypoglycaemia unawareness in the early stages of disease. However, declining endogenous insulin secretory capacity due to beta-cell dysfunction/failure eventually produces vulnerability similar to type 1 diabetes. Severe hypoglycaemia itself is associated with serious morbidity and sometimes mortality, and represents an important barrier to achieving glycaemic goals and thus may reduce the protection from diabetes-related morbidity provided by good glycaemic control. Achieving an optimal balance of good glycaemic control and low risk of hypoglycaemia is key to providing optimum care in individuals with type 2 diabetes. This article discusses the issues related specifically to hypoglycaemia associated with oral agent therapy and how these agents may be best employed to provide an optimal balance between hypoglycaemia and good glycaemic control. METHODS Embase and Medline searches from 1998 to 2009 using the search terms DPP-4 inhibitors, metformin, oral agents, sulphonylureas, thiazolidinediones AND hypoglycaemia were conducted to identify relevant articles. The limitations inherent in this retrospective, narrative review of previously published publications chosen at the author's discretion are acknowledged. FINDINGS Failure to address even mild hypoglycaemia and glycaemic control early in the course of the disease may compromise the success of treatment in the longer term. Metformin, thiazolidinediones and DPP-4 inhibitors, either as monotherapy or in combination with each other, have a well-characterised low propensity to cause hypoglycaemia compared with other therapies. CONCLUSIONS Metformin, thiazolidinediones and DPP-4 inhibitors appear to be the most appropriate oral options for minimising the risk of hypoglycaemia. Early and ongoing attention to hypoglycaemia should form an integral part of any long-term glucose control strategy.
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Affiliation(s)
- Anthony H Barnett
- University of Birmingham and Heart of England NHS Foundation Trust, Birmingham, UK.
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Rodríguez A, Ciprés L, Tofé S, Polavieja P, Reviriego J. Clinical evaluation of combined therapy for type 2 diabetes. Curr Med Res Opin 2010; 26:1171-83. [PMID: 20297952 DOI: 10.1185/03007991003733239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Therapeutic guidelines recommend the combination of drugs as necessary to control type 2 diabetes (T2D). This research assessed the effectiveness of pioglitazone (Pio), metformin (Met) and sulfonylurea (SU) combinations in the routine clinical practice. RESEARCH DESIGN AND METHODS A nationwide, 12-month prospective, observational cohort study was performed in 2294 patients with T2D (50.3% females, mean age: 61.1 years, mean body mass index: 30.2 kg/m(2), mean time since diagnosis: 8.5 years) who started, at the discretion of treating physician, oral antihyperglycaemic treatment with either Pio + SU, Pio + Met or SU + Met because of inadequate control with previous therapy. Fasting plasma glucose (FPG), glycohaemoglobin (HbA1c), lipids, blood pressure, and anthropometric parameters were measured, and 10-year cardiovascular risk was estimated. RESULTS FPG, HbA1c and total cholesterol at baseline had mean values (184.6 mg/dl, 8.5% and 246.0 mg/dl, respectively) associated with an excess of micro- and macrovascular risk. The mean changes from baseline in the Pio + SU, Pio + Met and SU + Met cohorts were, respectively, -37.9, -32.7 and -25.8 mg/dl for FPG; -1.1, -1.0 and -0.7% for HbA1c; -30.7, -38.7 and -17.1 mg/dl for triglycerides; and +2.3, +2.5 and +0.6 mg/dl for HDL cholesterol. In consequence, the estimated 10-year cardiovascular risk decreased more in the Pio cohorts, particularly with Pio + Met (1.7% versus 1.4% Pio + SU and 1.0% SU + Met -Framingham equation- and 0.6% versus 0.4% SU + Met - Systematic Coronary Risk Evaluation model-). Related adverse events were significantly (p = 0.016) more frequent in Pio cohorts (4.7% with Pio + SU, 5.1% with Pio + Met) than in the SU + Met cohort (2.4%). CONCLUSIONS In patients with T2D failing therapy, mostly SU or Met monotherapy, pioglitazone add-on treatment was associated with a significant improvement of micro- and macrovascular risk estimations. These results from real-life clinical conditions support the findings of prior randomised trials, although they should be interpreted with caution because of the observational, nonrandomised design.
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Bain SC. Treatment of type 2 diabetes mellitus with orally administered agents: advances in combination therapy. Endocr Pract 2010; 15:750-62. [PMID: 19625236 DOI: 10.4158/ep08317.rar] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To discuss the effects and clinical benefit provided by combining various orally administered antidiabetic drugs (OADs) for the treatment of type 2 diabetes and to examine the advantages of single-tablet combinations with respect to targeting hyperglycemia and adherence. METHODS A review of randomized controlled trials that studied OAD combinations for the treatment of type 2 diabetes was conducted by using search terms in PubMed. RESULTS Reported data have documented that OAD combination therapies have additional benefits over monotherapy in terms of glycemic efficacy. Results from randomized controlled trials on a range of OAD combinations have demonstrated differences in safety and efficacy. The use of single-tablet OAD combinations has been shown to improve adherence in patients. CONCLUSION The development of single-tablet OAD combinations that can address all aspects of glycemia with a favorable tolerability profile has the potential to help patients manage their glycemic control more effectively and to minimize the risk of long-term diabetes-related complications. In addition, single-tablet combinations of agents offer improved convenience for patients as well as potential cost benefits. Thus, they represent an important treatment option for type 2 diabetes.
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Affiliation(s)
- Stephen C Bain
- Institute of Life Sciences, Swansea University and Abertawe Bro Morgannwg University NHS Trust, Swansea, United Kingdom.
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Scherbaum WA, Goodall G, Erny-Albrecht KM, Massi-Benedetti M, Erdmann E, Valentine WJ. Cost-effectiveness of pioglitazone in type 2 diabetes patients with a history of macrovascular disease: a German perspective. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2009; 7:9. [PMID: 19416529 PMCID: PMC2688482 DOI: 10.1186/1478-7547-7-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 05/05/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to project health-economic outcomes relevant to the German setting for the addition of pioglitazone to existing treatment regimens in patients with type 2 diabetes, evidence of macrovascular disease and at high risk of cardiovascular events. METHODS Event rates corresponding to macrovascular outcomes from the Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROactive) study of pioglitazone were used with a modified version of the CORE Diabetes Model to simulate outcomes over a 35-year time horizon. Direct medical costs were accounted from a healthcare payer perspective in year 2005 values. Germany specific costs were applied for patient treatment, hospitalization and management. Both costs and clinical benefits were discounted at 5.0% per annum. RESULTS Over patient lifetimes pioglitazone treatment improved undiscounted life expectancy by 0.406 years and improved quality-adjusted life expectancy by 0.120 quality-adjusted life years (QALYs) compared to placebo. Direct medical costs (treatment plus complication costs) were marginally higher for pioglitazone treatment and calculation of the incremental cost-effectiveness ratio (ICER) produced a value of euro13,294 per QALY gained with the pioglitazone regimen versus placebo. Acceptability curve analysis showed that there was a 78.2% likelihood that pioglitazone would be considered cost-effective in Germany, using a "good value for money" threshold of euro50,000 per QALY gained. Sensitivity analyses showed that the results were most sensitive to changes in the simulation time horizon. After adjustment for the potential stabilization of pancreatic beta-cell function with pioglitazone treatment, the ICER was euro6,667 per QALY gained for pioglitazone versus placebo. CONCLUSION The findings of this modelling analysis indicated that, for patients with a history of macrovascular disease, addition of pioglitazone to existing therapy reduces the long-term cumulative incidence of diabetes-complications at a cost that would be considered to represent good value for money in the German setting.
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Defronzo RA. Banting Lecture. From the triumvirate to the ominous octet: a new paradigm for the treatment of type 2 diabetes mellitus. Diabetes 2009; 58:773-95. [PMID: 19336687 PMCID: PMC2661582 DOI: 10.2337/db09-9028] [Citation(s) in RCA: 1854] [Impact Index Per Article: 123.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Ralph A Defronzo
- Diabetes Division, University of Texas Health Science Center, San Antonio, Texas, USA.
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Tolerability outcomes of a multicenter, observational, open-label, drug-surveillance study in patients with type 2 diabetes mellitus treated with pioglitazone for 2 years. Clin Ther 2009; 31:74-88. [DOI: 10.1016/j.clinthera.2009.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2008] [Indexed: 11/17/2022]
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Rodríguez Á, Reviriego J, Polavieja P, Mesa J. Efectividad y tolerabilidad a 6 meses de la pioglitazona en combinación con sulfonilureas o metformina en el tratamiento de la diabetes mellitus tipo 2. Med Clin (Barc) 2008; 131:721-30. [DOI: 10.1016/s0025-7753(08)75486-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Rizos CV, Liberopoulos EN, Mikhailidis DP, Elisaf MS. Pleiotropic effects of thiazolidinediones. Expert Opin Pharmacother 2008; 9:1087-108. [DOI: 10.1517/14656566.9.7.1087] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Busse FP, Stumvoll M. ADOPT: evidence for early use of thiazolidinediones. Expert Rev Endocrinol Metab 2007; 2:121-124. [PMID: 30754180 DOI: 10.1586/17446651.2.2.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Franziska Philomena Busse
- a University of Leipzig, Third Medical Department, Philipp-Rosenthal-Str. 27 04103 Leipzig, Germany.
| | - Michael Stumvoll
- b University of Leipzig, Third Medical Department, Philipp-Rosenthal-Str. 27 04103 Leipzig, Germany.
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