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Links between Metabolic Syndrome and Hypertension: The Relationship with the Current Antidiabetic Drugs. Metabolites 2023; 13:metabo13010087. [PMID: 36677012 PMCID: PMC9863091 DOI: 10.3390/metabo13010087] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/23/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
Hypertension poses a significant burden in the general population, being responsible for increasing cardiovascular morbidity and mortality, leading to adverse outcomes. Moreover, the association of hypertension with dyslipidaemia, obesity, and insulin resistance, also known as metabolic syndrome, further increases the overall cardiovascular risk of an individual. The complex pathophysiological overlap between the components of the metabolic syndrome may in part explain how novel antidiabetic drugs express pleiotropic effects. Taking into consideration that a significant proportion of patients do not achieve target blood pressure values or glucose levels, more efforts need to be undertaken to increase awareness among patients and physicians. Novel drugs, such as incretin-based therapies and renal glucose reuptake inhibitors, show promising results in decreasing cardiovascular events in patients with metabolic syndrome. The effects of sodium-glucose co-transporter-2 inhibitors are expressed at different levels, including renoprotection through glucosuria, natriuresis and decreased intraglomerular pressure, metabolic effects such as enhanced insulin sensitivity, cardiac protection through decreased myocardial oxidative stress and, to a lesser extent, decreased blood pressure values. These pleiotropic effects are also observed after treatment with glucagon-like peptide-1 receptor agonists, positively influencing the cardiovascular outcomes of patients with metabolic syndrome. The initial combination of the two classes may be the best choice in patients with type 2 diabetes mellitus and multiple cardiovascular risk factors because of their complementary mechanisms of action. In addition, the novel mineralocorticoid receptor antagonists show significant cardio-renal benefits, as well as anti-inflammatory and anti-fibrotic effects. Overall, the key to better control of hypertension in patients with metabolic syndrome is to consider targeting multiple pathogenic mechanisms, using a combination of the different therapeutic agents, as well as drastic lifestyle changes. This article will briefly summarize the association of hypertension with metabolic syndrome, as well as take into account the influence of antidiabetic drugs on blood pressure control.
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Blood Pressure-Lowering Effect of Newer Antihyperglycemic Agents (SGLT-2 Inhibitors, GLP-1 Receptor Agonists, and DPP-4 Inhibitors). Am J Cardiovasc Drugs 2021; 21:123-137. [PMID: 32780214 DOI: 10.1007/s40256-020-00423-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The prevalence of arterial hypertension is high in patients with diabetes mellitus (DM). When DM and hypertension coexist, they constitute a dual cardiovascular threat and should be adequately controlled. Novel antihyperglycemic agents, including sodium-glucose co-transporter 2 (SGLT-2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), and dipeptidyl peptidase-4 (DPP-4) inhibitors, have recently been used in the treatment of DM. Beyond their glucose-lowering effects, these drugs have shown beneficial pleiotropic cardiovascular effects, including lowering of arterial blood pressure (BP), as acknowledged in the 2019 European Society of Cardiology/European Association for the Study of Diabetes guidelines on diabetes, prediabetes, and cardiovascular diseases. The purpose of this review was to summarize the available information on the BP-reducing effects of these new glucose-lowering drug classes and provide a brief report on underlying pathophysiological mechanisms. We also compare the three drug classes (SGLT-2 inhibitors, GLP-1 RAs, and DPP-4 inhibitors) in terms of their BP-lowering effect and show that the greater BP reduction seems to be achieved with SGLT-2 inhibitors, whereas DPP-4 inhibitors have probably the mildest antihypertensive effect.
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Elnaem MH, Mansour NO, Nahas AF, Baraka MA, Elkalmi R, Cheema E. Renal Outcomes Associated with the Use of Non-Insulin Antidiabetic Pharmacotherapy: A Review of Current Evidence and Recommendations. Int J Gen Med 2020; 13:1395-1409. [PMID: 33324086 PMCID: PMC7733337 DOI: 10.2147/ijgm.s285191] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/12/2020] [Indexed: 01/17/2023] Open
Abstract
Background This study aims to discuss, summarize and compare the renal outcomes associated with non-insulin antidiabetic (AD) pharmacotherapy prescribed for patients with type 2 diabetes mellitus (T2DM). Methods A systematic search using predefined search terms in three scholarly databases, ScienceDirect, Google Scholar, and PubMed, was conducted. Original research articles published in the English language between 2012 and 2020 that reported renal outcomes associated with the use of non-insulin AD pharmacotherapy were eligible for inclusion. Review articles, meta-analysis studies, and conference proceedings were excluded. A study-specific data extraction form was designed to extract the author’s name, country, publication year, study design, study population, objectives, key findings, and conclusions. A narrative review of the key findings that focused on renal outcomes and renal safety issues was conducted. Results Of the 18,872 results identified through the initial search, a total of 32 articles were included in this review. Of these, 18 of the included articles reported the renal outcomes of newer antidiabetic medications, eg, SGLT2 inhibitors and GLP-1 agonists. Eight studies focussed on the well-established antidiabetic medications, eg, metformin and sulphonylureas. The review reported three main types of the clinical impact of the prescribed AD on the renal outcomes: “renoprotective effects”, “no additional risk” and “associated with a decline in renal parameters”. Seventeen studies reported the renoprotective effects of AD, including SGLT2i studies (n=8), GLP1 studies (n=6), and DPP4i studies (n=3). The reported renoprotective effects included slowing down the GFR decline, improving albuminuria, and reducing renal adverse events. The “no additional risk” impact was reported in eight studies, including DPP4i studies (n=3), two SGLT2i studies (n=2), metformin studies (n=2), and one study involving pioglitazone. Furthermore, seven studies highlighted the “associated with a decline in renal parameters” effect. Of these, three involved SGLT2i, two with metformin, and one for each DPP4i and sulphonylurea. Conclusion More than half of the studies included in this review supported the renoprotective effects associated with the use of AD medications, particularly GLP-1A, SGLT2i, and some of the DPP4i. Further studies involving patients with various stages of chronic kidney disease (CKD) are required to compare AD medications’ renal effects, particularly the newer agents.
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Affiliation(s)
- Mohamed Hassan Elnaem
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang.,Quality Use of Medicines Research Group, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang
| | - Noha O Mansour
- Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Cairo, Egypt
| | - Abdulrahman Fata Nahas
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang.,Quality Use of Medicines Research Group, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang
| | - Mohamed A Baraka
- Department of Clinical Pharmacy, College of Pharmacy, Al Ain University, Al Ain, United Arab Emirates.,Department of Clinical Pharmacy, College of Pharmacy, Al-Azhar University, Cairo, Egypt
| | - Ramadan Elkalmi
- Department of Clinical Pharmacy and Pharmacotherapeutics, Dubai Pharmacy College, Dubai, United Arab Emirates.,Department of Pharmacology, Faculty of Medicine, Sebha University, Sabha, Libya
| | - Ejaz Cheema
- School of Pharmacy, University of Birmingham, Birmingham B15 2TT, UK
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Kim G, Lim S, Kwon H, Park IB, Ahn KJ, Park C, Kwon SK, Kim HS, Park SW, Kim SG, Moon MK, Kim ES, Chung CH, Park KS, Kim M, Chung DJ, Lee CB, Kim TH, Lee M. Efficacy and safety of evogliptin treatment in patients with type 2 diabetes: A multicentre, active-controlled, randomized, double-blind study with open-label extension (the EVERGREEN study). Diabetes Obes Metab 2020; 22:1527-1536. [PMID: 32319168 PMCID: PMC7496811 DOI: 10.1111/dom.14061] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 02/07/2023]
Abstract
AIM To investigate the efficacy and safety of evogliptin compared with linagliptin in patients with type 2 diabetes. MATERIALS AND METHODS In this 12-week, multicentre, randomized, double-blind, active-controlled, and 12-week open-label extension study, a total of 207 patients with type 2 diabetes who had HbA1c levels of 7.0%-10.0% were randomized 1:1 to receive evogliptin 5 mg (n = 102) or linagliptin 5 mg (n = 105) daily for 12 weeks. The primary efficacy endpoint was the change from baseline HbA1c at week 12. The secondary endpoint was the change in the mean amplitude of glycaemic excursion (MAGE) assessed by continuous glucose monitoring. In the extension study conducted during the following 12 weeks, evogliptin 5 mg daily was administered to both groups: evogliptin/evogliptin group (n = 95) and linagliptin/evogliptin group (n = 92). RESULTS After 12 weeks of treatment, the mean change in HbA1c in the evogliptin group and in the linagliptin group was -0.85% and -0.75%, respectively. The between-group difference was -0.10% (95% CI: -0.32 to 0.11), showing non-inferiority based on a non-inferiority margin of 0.4%. The change in MAGE was -24.6 mg/dL in the evogliptin group and -16.7 mg/dL in the linagliptin group. These values were significantly lower than the baseline values in both groups. However, they did not differ significantly between the two groups. In the evogliptin/evogliptin group at week 24, HbA1c decreased by -0.94%, with HbA1c values of <7.0% in 80.2% of the patients. The incidence and types of adverse events were comparable between the two groups for 24 weeks. CONCLUSION In this study, the glucose-lowering efficacy of evogliptin was non-inferior to linagliptin. It was maintained at week 24 with a 0.94% reduction in HbA1c. Evogliptin therapy improved glycaemic variability without causing any serious adverse events in patients with type 2 diabetes.
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Affiliation(s)
- Gyuri Kim
- Department of Medicine, Samsung Medical CenterSungkyunkwan UniversitySeoulKorea
| | - Soo Lim
- Department of Internal Medicine, Seoul National University College of MedicineSeoul National University Bundang HospitalSeongnamKorea
| | - Hyuk‐Sang Kwon
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of MedicineThe Catholic University of KoreaSeoulKorea
| | - Ie B. Park
- Department of Internal MedicineGachon University Gil Medical CenterIncheonKorea
| | - Kyu J. Ahn
- Department of Internal MedicineKangdong Kyung Hee University HospitalSeoulKorea
| | - Cheol‐Young Park
- Department of Internal MedicineKangbuk Samsung HospitalSeoulKorea
| | - Su K. Kwon
- Department of Internal MedicineKosin University Gospel HospitalBusanKorea
| | - Hye S. Kim
- Department of Internal MedicineKeimyung University Dongsan Medical CenterDaeguKorea
| | - Seok W. Park
- Department of Internal MedicineYonsei University College of MedicineSeoulKorea
| | - Sin G. Kim
- Department of Internal MedicineKorea University Anam HospitalSeoulKorea
| | - Min K. Moon
- Department of Internal MedicineSeoul National University Boramae Medical CenterSeoulKorea
| | - Eun S. Kim
- Department of Internal Medicine, Ulsan University HospitalCollege of Medicine University of UlsanUlsanKorea
| | - Choon H. Chung
- Department of Internal MedicineWonju Severance Christian HospitalWonjuKorea
| | - Kang S. Park
- Department of Internal MedicineEulji University HospitalDaejeonKorea
| | - Mikyung Kim
- Department of Internal MedicineInje University Haeundae Paik HospitalBusanKorea
| | - Dong J. Chung
- Department of Internal Medicine, Chonnam National University Medical SchoolChonnam National University HospitalGwangjuKorea
| | - Chang B. Lee
- Department of Internal MedicineHanyang University Guri HospitalGuriKorea
| | - Tae H. Kim
- Department of Internal MedicineSeoul Medical CenterSeoulKorea
| | - Moon‐Kyu Lee
- Department of Internal MedicineSoonchunhyang University Gumi HospitalGumiSouth Korea
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5
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Fazeli Farsani S, Taniguchi A, Ikeda R, Brodovicz KG, Bartels DB. Preferential prescribing of linagliptin in type 2 diabetes patients in an expanded post-marketing surveillance study in Japan. J Diabetes Investig 2019; 10:1246-1253. [PMID: 30667173 PMCID: PMC6717825 DOI: 10.1111/jdi.13012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 11/28/2022] Open
Abstract
AIMS/INTRODUCTION To evaluate linagliptin prescribing in type 2 diabetes mellitus patients with different comorbidities, an expanded Japanese post-marketing surveillance also collected baseline data for patients initiating other glucose-lowering drugs. MATERIALS AND METHODS Patients initiating linagliptin monotherapy were enrolled, then the next patient starting monotherapy with another glucose-lowering drug was enrolled (2012-2014). Baseline data were collected and analyzed by the Medical Dictionary for Regulatory Activities system organ class. Analyses were descriptive, and meaningful differences defined as absolute standardized difference >10%. RESULTS Over 4,200 type 2 diabetes mellitus patients were enrolled. Most system-organ class comorbidities were more common in patients initiating linagliptin versus other glucose-lowering drugs, with meaningful differences observed for metabolism/nutritional (50.5 vs 45.5%, respectively), cardiac (12.2 vs 8.6%, respectively), vascular (56.4 vs 51.3%, respectively) and renal/urinary disorders (9.9 vs 5.7%, respectively). CONCLUSIONS Expanding the linagliptin Japanese post-marketing surveillance revealed linagliptin prescribing to a type 2 diabetes mellitus population with more comorbidities versus other glucose-lowering drugs. Although such preferential prescribing might be expected, as linagliptin requires no dose adjustment or monitoring in renally or hepatically impaired patients, this innovative post-marketing surveillance approach generated important evidence that could only be shown in such a non-randomized comparative study. These data generated insights important for the design and interpretation of observational studies and spontaneous reports, which are key for public health.
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Affiliation(s)
| | - Atsushi Taniguchi
- Biostatistics & Data ScienceNippon Boehringer Ingelheim Co., Ltd.TokyoJapan
| | - Rie Ikeda
- Pharmacovigilance DepartmentNippon Boehringer Ingelheim Co., Ltd.TokyoJapan
| | - Kimberly G Brodovicz
- Global EpidemiologyBoehringer Ingelheim Pharmaceuticals Inc.RidgefieldConnecticutUSA
| | - Dorothee B Bartels
- Hannover Medical SchoolInstitute for EpidemiologySocial Medicine and Health Systems ResearchHannoverGermany
- BI X GmbHIngelheim am RheinGermany
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Patorno E, Gopalakrishnan C, Brodovicz KG, Meyers A, Bartels DB, Liu J, Kulldorff M, Schneeweiss S. Cardiovascular safety of linagliptin compared with other oral glucose-lowering agents in patients with type 2 diabetes: A sequential monitoring programme in routine care. Diabetes Obes Metab 2019; 21:1824-1836. [PMID: 30941884 PMCID: PMC6785989 DOI: 10.1111/dom.13735] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/22/2019] [Accepted: 03/31/2019] [Indexed: 01/07/2023]
Abstract
AIM To evaluate the safety of linagliptin versus other glucose-lowering medications in a multi-year monitoring programme using insurance claims data. METHODS In two commercial US claims databases, we identified three pairwise 1:1 propensity-score (PS)-matched cohorts of patients with type 2 diabetes (T2D) aged ≥18 years initiating linagliptin or a comparator (other dipeptidyl peptidase-4 [DPP-4] inhibitors [n = 31 492 pairs], pioglitazone [n = 23 316 pairs], or second-generation sulphonylureas [n = 19 731 pairs]) between May 2011 and December 2015. The primary endpoint was the risk of a composite cardiovascular (CV) outcome (hospitalization for myocardial infarction, stroke, unstable angina, or coronary revascularization). We estimated pooled hazard ratios (HRs) and 95% confidence intervals (CIs), controlling for >100 baseline characteristics. RESULTS Patient characteristics were well balanced after PS-matching. The mean age was 55 years and mean follow-up was 0.8 years. Linagliptin conferred a similar risk of the composite CV outcome compared to other DPP-4 inhibitors (HR 0.91, 95% CI 0.79-1.05) and pioglitazone (HR 0.98, 95% CI 0.84-1.15), and showed a reduced risk of CV outcomes compared to second-generation sulphonylureas (HR 0.76, 95% CI 0.64--0.92). Key findings were signalled at the first interim analysis in June 2013 and solidified during ongoing monitoring until 2015. CONCLUSION Analyses from a large monitoring programme in routine care of patients with T2D, showed that linagliptin had similar CV safety compared to other DPP-4 inhibitors and pioglitazone, and a reduced CV risk compared to sulphonylureas.
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Affiliation(s)
- Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Chandrasekar Gopalakrishnan
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kimberly G Brodovicz
- Department of Global Epidemiology, Boehringer Ingelheim Pharmaceuticals, Inc (U.S), Ingelheim, Germany
| | - Andrea Meyers
- Department of Global Epidemiology, Boehringer Ingelheim Pharmaceuticals, Inc (U.S), Ingelheim, Germany
| | - Dorothee B Bartels
- Hannover Medical School, Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover, Germany
- BI X, Boehringer Ingelheim GmbH, Ingelheim, Germany
| | - Jun Liu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Martin Kulldorff
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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7
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Bistola V, Lambadiari V, Dimitriadis G, Ioannidis I, Makrilakis K, Tentolouris N, Tsapas A, Parissis J. Possible mechanisms of direct cardiovascular impact of GLP-1 agonists and DPP4 inhibitors. Heart Fail Rev 2019; 23:377-388. [PMID: 29383638 DOI: 10.1007/s10741-018-9674-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetes mellitus is a leading cause of cardiovascular morbidity and mortality worldwide. Traditional antidiabetic therapies targeting hyperglycemia reduce diabetic microvascular complications but have minor effects on macrovascular complications, including cardiovascular disease. Instead, cardiovascular complications are improved by antidiabetic medications (metformin) and other therapies (statins, antihypertensive medications) ameliorating insulin resistance and other associated metabolic abnormalities. Novel classes of antidiabetic drugs have proven efficacious in improving glycemia, while at the same time exert beneficial effects on pathophysiologic mechanisms of diabetes-related cardiovascular disease. In the present review, we will present current evidence of the cardiovascular effects of two new classes of antidiabetic medications, glucagon-like peptide 1 (GLP-1) agonists and dipeptidyl peptidase-4 (DPP4) inhibitors, focusing from mechanistic preclinical and clinical investigation to late-phase clinical testing.
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Affiliation(s)
- Vasiliki Bistola
- Heart Failure Unit, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Rimini 1 Chaidari, 12461, Athens, Greece.
| | - Vaia Lambadiari
- 2nd Department of Internal medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - George Dimitriadis
- 2nd Department of Internal medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Ioannis Ioannidis
- Diabetes and Obesity Center, Konstantopouleio Hospital, Athens, Greece
| | - Konstantinos Makrilakis
- First Department of Propaedeutic Internal Medicine, Diabetes Center, National and Kapodistrian University of Athens Medical School, Laiko General Hospital, Athens, Greece
| | - Nikolaos Tentolouris
- First Department of Propaedeutic Internal Medicine, Diabetes Center, National and Kapodistrian University of Athens Medical School, Laiko General Hospital, Athens, Greece
| | - Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - John Parissis
- Heart Failure Unit, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Medical School, Rimini 1 Chaidari, 12461, Athens, Greece
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8
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Li D, Shi W, Wang T, Tang H. SGLT2 inhibitor plus DPP-4 inhibitor as combination therapy for type 2 diabetes: A systematic review and meta-analysis. Diabetes Obes Metab 2018; 20:1972-1976. [PMID: 29573110 DOI: 10.1111/dom.13294] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/10/2018] [Accepted: 03/15/2018] [Indexed: 01/11/2023]
Abstract
To assess the efficacy and safety of sodium-glucose co-transporter 2 (SGLT2) inhibitors plus a dipeptidyl peptidase-4 (DPP-4) inhibitor in patients with type 2 diabetes mellitus (T2DM), we performed a systematic review and meta-analysis of 14 randomized controlled trials (RCTs) involving 4828 patients. Compared with a DPP-4 inhibitor, SGLT2 inhibitor/DPP-4 inhibitor combination therapy was significantly associated with a decrease in glycaemic control (HbA1c, -0.71%; fasting plasma glucose [FPG], -25.62 mg/dL; postprandial plasma glucose, -44.00 mg/dL), body weight (-2.05 kg) and systolic blood pressure (-5.90 mm Hg), but an increase in total cholesterol (TC) of 3.24%, high-density lipoprotein of 6.15% and low-density lipoprotein of 2.55%. Adding a DPP-4 inhibitor to an SGLT2 inhibitor could reduce HbA1c by -0.31%, FPG by -8.94 mg/dL, TC by -1.48% and triglycerides by -3.25%. Interestingly, low doses of an SGLT2 inhibitor in the combination has similar or even better efficacy in some aspects than high doses. Similar adverse events were observed for the combination therapy, with the exception of genital infection vs DPP-4 inhibitor (risk ratio [RR], 5.31) and consistent genital infection vs an SGLT2 inhibitor (RR, 0.61). Further studies are warranted to confirm these results.
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Affiliation(s)
- Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Weilong Shi
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Tiansheng Wang
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Huilin Tang
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
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9
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Tomovic K, Lazarevic J, Kocic G, Deljanin-Ilic M, Anderluh M, Smelcerovic A. Mechanisms and pathways of anti-inflammatory activity of DPP-4 inhibitors in cardiovascular and renal protection. Med Res Rev 2018; 39:404-422. [DOI: 10.1002/med.21513] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 04/27/2018] [Accepted: 05/03/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Katarina Tomovic
- Department of Pharmacy, Faculty of Medicine; University of Nis; Bulevar Dr Zorana Djindjica 81 18000 Nis Serbia
| | - Jelena Lazarevic
- Department of Chemistry, Faculty of Medicine; University of Nis; Bulevar Dr Zorana Djindjica 81 18000 Nis Serbia
| | - Gordana Kocic
- Institute of Biochemistry, Faculty of Medicine; University of Nis; Bulevar Dr Zorana Djindjica 81 18000 Nis Serbia
| | - Marina Deljanin-Ilic
- Institute for Cardiovascular Rehabilitation, Faculty of Medicine; University of Nis; 18205 Niska Banja Serbia
| | - Marko Anderluh
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy; University of Ljubljana; Askerceva 7 SI-1000 Ljubljana Slovenia
| | - Andrija Smelcerovic
- Department of Chemistry, Faculty of Medicine; University of Nis; Bulevar Dr Zorana Djindjica 81 18000 Nis Serbia
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10
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Aroor AR, Manrique-Acevedo C, DeMarco VG. The role of dipeptidylpeptidase-4 inhibitors in management of cardiovascular disease in diabetes; focus on linagliptin. Cardiovasc Diabetol 2018; 17:59. [PMID: 29669555 PMCID: PMC5907287 DOI: 10.1186/s12933-018-0704-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/12/2018] [Indexed: 12/15/2022] Open
Abstract
Multiple population based analyses have demonstrated a high incidence of cardiovascular disease (CVD) and cardiovascular (CV) mortality in subjects with T2DM that reduces life expectancy by as much as 15 years. Importantly, the CV system is particularly sensitive to the metabolic and immune derangements present in obese pre-diabetic and diabetic individuals; consequently, CV dysfunction is often the initial CV derangement to occur and promotes the progression to end organ/tissue damage in T2DM. Specifically, diabetic CVD can manifest as microvascular complications, such as nephropathy, retinopathy, and neuropathy, as well as, macrovascular impairments, including ischemic heart disease, peripheral vascular disease, and cerebrovascular disease. Despite some progress in prevention and treatment of CVD, mainly via blood pressure and dyslipidemia control strategies, the impact of metabolic disease on CV outcomes is still a major challenge and persists in proportion to the epidemics of obesity and diabetes. There is abundant pre-clinical and clinical evidence implicating the DPP-4-incretin axis in CVD. In this regard, linagliptin is a unique DPP-4 inhibitor with both CV and renal safety profiles. Moreover, it exerts beneficial CV effects beyond glycemic control and beyond class effects. Linagliptin is protective for both macrovascular and microvascular complications of diabetes in preclinical models, as well as clinical models. Given the role of endothelial-immune cell interactions as one of the key events in the initiation and progression of CVD, linagliptin modulates these cell–cell interactions by affecting two important pathways involving stimulation of NO signaling and potent inhibition of a key immunoregulatory molecule.
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Affiliation(s)
- Annayya R Aroor
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO, USA.,Division of Endocrinology and Metabolism, Department of Medicine, University of Missouri-Columbia School of Medicine, One Hospital Drive, Columbia, MO, 65212, USA.,Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA
| | - Camila Manrique-Acevedo
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO, USA.,Division of Endocrinology and Metabolism, Department of Medicine, University of Missouri-Columbia School of Medicine, One Hospital Drive, Columbia, MO, 65212, USA.,Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA
| | - Vincent G DeMarco
- Diabetes and Cardiovascular Center, University of Missouri School of Medicine, Columbia, MO, USA. .,Division of Endocrinology and Metabolism, Department of Medicine, University of Missouri-Columbia School of Medicine, One Hospital Drive, Columbia, MO, 65212, USA. .,Research Service, Harry S. Truman Memorial Veterans Hospital, Columbia, MO, USA. .,Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, MO, USA.
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11
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Kanasaki K. The role of renal dipeptidyl peptidase-4 in kidney disease: renal effects of dipeptidyl peptidase-4 inhibitors with a focus on linagliptin. Clin Sci (Lond) 2018; 132:489-507. [PMID: 29491123 PMCID: PMC5828949 DOI: 10.1042/cs20180031] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 02/12/2018] [Accepted: 02/13/2018] [Indexed: 12/15/2022]
Abstract
Emerging evidence suggests that dipeptidyl peptidase-4 (DPP-4) inhibitors used to treat type 2 diabetes may have nephroprotective effects beyond the reduced renal risk conferred by glycemic control. DPP-4 is a ubiquitous protein with exopeptidase activity that exists in cell membrane-bound and soluble forms. The kidneys contain the highest levels of DPP-4, which is increased in diabetic nephropathy. DPP-4 inhibitors are a chemically heterogeneous class of drugs with important pharmacological differences. Of the globally marketed DPP-4 inhibitors, linagliptin is of particular interest for diabetic nephropathy as it is the only compound that is not predominantly excreted in the urine. Linagliptin is also the most potent DPP-4 inhibitor, has the highest affinity for this protein, and has the largest volume of distribution; these properties allow linagliptin to penetrate kidney tissue and tightly bind resident DPP-4. In animal models of kidney disease, linagliptin elicited multiple renoprotective effects, including reducing albuminuria, glomerulosclerosis, and tubulointerstitial fibrosis, independent of changes in glucagon-like peptide-1 (GLP-1) and glucose levels. At the molecular level, linagliptin prevented the pro-fibrotic endothelial-to-mesenchymal transition by disrupting the interaction between membrane-bound DPP-4 and integrin β1 that enhances signaling by transforming growth factor-β1 and vascular endothelial growth factor receptor-1. Linagliptin also increased stromal cell derived factor-1 levels, ameliorated endothelial dysfunction, and displayed unique antioxidant effects. Although the nephroprotective effects of linagliptin are yet to be translated to the clinical setting, the ongoing Cardiovascular and Renal Microvascular Outcome Study with Linagliptin in Patients with Type 2 Diabetes Mellitus (CARMELINA®) study will definitively assess the renal effects of this DPP-4 inhibitor. CARMELINA® is the only clinical trial of a DPP-4 inhibitor powered to evaluate kidney outcomes.
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Affiliation(s)
- Keizo Kanasaki
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Japan
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Japan
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Dey J. SGLT2 inhibitor/DPP-4 inhibitor combination therapy - complementary mechanisms of action for management of type 2 diabetes mellitus. Postgrad Med 2017; 129:409-420. [PMID: 28322073 DOI: 10.1080/00325481.2017.1307081] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Type 2 diabetes mellitus is a progressive disease with multiple underlying pathophysiologic defects. Monotherapy alone cannot maintain glycemic control and leads to treatment failure. Ideally, a combination of glucose-lowering agents should have complementary mechanisms of action that address multiple pathophysiologic pathways, can be used at all stages of the disease, and be generally well tolerated with no increased risk of hypoglycemia, cardiovascular events, or weight gain. The combination should also provide conveniences for patients, such as oral dosing, single-pill formulations, and once-daily administration, potentially translating to improved adherence. Two classes of glucose-lowering agents that meet these criteria are the sodium glucose cotransporter-2 (SGLT2) inhibitors and dipeptidyl peptidase-4 (DPP-4) inhibitors. This article reviews the rationale for combination therapy with these agents, and evidence from clinical trials with empagliflozin and linagliptin or dapagliflozin and saxagliptin in the management of type 2 diabetes mellitus. Both combinations have been approved as single-pill formulations.
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Affiliation(s)
- Jayant Dey
- a Endocrine & Metabolic Disorders Institute , Tupelo , MS , USA
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Oh J, Kim AH, Lee S, Cho H, Kim YS, Bahng MY, Yoon SH, Cho JY, Jang IJ, Yu KS. Effects of renal impairment on the pharmacokinetics and pharmacodynamics of a novel dipeptidyl peptidase-4 inhibitor, evogliptin (DA-1229). Diabetes Obes Metab 2017; 19:294-298. [PMID: 27761990 DOI: 10.1111/dom.12813] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/10/2016] [Accepted: 10/17/2016] [Indexed: 02/06/2023]
Abstract
Evogliptin is a novel potent and selective dipeptidyl peptidase-4 (DPP-4) inhibitor. The aim of the present study was to evaluate the pharmacokinetic (PK) and pharmacodynamic (PD) characteristics of evogliptin in participants with renal impairment (RI). An open-label, parallel-group clinical study was conducted in participants with mild, moderate and severe RI and in matched participants with normal renal function (NRF). A single oral 5-mg dose of evogliptin was administered and serial blood and urine samples were obtained to assess the PK and PD characteristics of evogliptin. Baseline urine samples were collected to evaluate endogenous CYP3A metabolic markers. The plasma exposure to evogliptin and degree of DPP-4 activity inhibition increased with decreasing renal function. The mean areas under the concentration-time curves from 0 to 120 hours were increased 1.2-, 1.8- and 1.98-fold in the mild, moderate and severe RI groups, respectively, compared with the NRF group. The levels of CYP3A metabolic markers were lower in the RI group than in the NRF group. The increase in the plasma concentration of evogliptin is unlikely to result in changes in its efficacy or safety, considering the results of previous clinical studies.
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Affiliation(s)
- Jaeseong Oh
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Andrew HyoungJin Kim
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - SeungHwan Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Hyunjeong Cho
- Department of Internal Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Mi Young Bahng
- Department of Product Development, Dong-A ST Co. Ltd, Seoul, Korea
| | - Seo Hyun Yoon
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Joo-Youn Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - In-Jin Jang
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Korea
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Cardiovascular Safety of Incretin-Based Therapies in Type 2 Diabetes: Systematic Review of Integrated Analyses and Randomized Controlled Trials. Adv Ther 2017; 34:1-40. [PMID: 27844335 PMCID: PMC5216099 DOI: 10.1007/s12325-016-0432-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Indexed: 12/25/2022]
Abstract
Introduction Regulatory requirements mandate that new drugs for treatment of patients with type 2 diabetes mellitus (T2DM), such as dipeptidyl peptidase-4 (DPP-4) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists, are evaluated to show that they do not increase cardiovascular (CV) risk. Methods A systematic review was undertaken to evaluate the association between DPP-4 inhibitor and GLP-1 receptor agonist use and major adverse cardiac events (MACE). The National Institutes of Health Medline database was searched for pooled analyses, meta-analyses, and randomized controlled trials (RCTs) of DPP-4 inhibitors and GLP-1 receptor agonists that included CV endpoints. Results Thirty-six articles met the inclusion criteria encompassing 11 pooled analyses, 17 meta-analyses, and eight RCTs (including secondary analyses). Over the short term (up to 4 years), patients with T2DM exposed to a DPP-4 inhibitor or GLP-1 receptor agonist were not at increased risk for MACE (or its component endpoints) compared with those who received comparator agents. Two meta-analyses showed a significant reduction in the incidence of MACE associated with DPP-4 inhibitor therapy as a drug class, but this beneficial effect was not observed in other meta-analyses that included large RCT CV outcome studies. In four RCTs that evaluated alogliptin, saxagliptin, sitagliptin, or lixisenatide, there was no overall increased risk for MACE relative to placebo in T2DM patients at high risk for CV events or with established CV disease, although there was an increased rate of hospitalization for heart failure associated with saxagliptin. A fifth RCT showed that liraglutide reduced MACE risk by 13% versus placebo. Conclusion Overall, incretin therapy does not appear to increase risk for MACE in the short term.
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Effects of dipeptidyl peptidase-4 inhibitors on blood pressure in patients with type 2 diabetes: A systematic review and meta-analysis. J Hypertens 2016; 34:167-75. [PMID: 26682782 DOI: 10.1097/hjh.0000000000000782] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This review was undertaken to assess the effects of dipeptidyl peptidase-4 (DPP-4) inhibitors on blood pressure (BP) in patients with type 2 diabetes (T2DM). We searched three main databases (PubMed, Web of Science, and Scopus) for relevant articles. Randomized controlled trials which reported BP changes from baseline to study endpoint in patients with T2DM receiving treatment of DPP-4 inhibitors were included for analysis. Random effects models were used to measure the mean differences with 95% confidence intervals (CIs). Fifteen trials involving 5636 participants were identified. When compared with placebo or nontreatment, DPP-4 inhibitors achieved greater reductions for both SBP (mean difference, -3.04 mmHg; 95% CI, -4.37 to -1.72; P < 0.00001) and DBP (mean difference, -1.47 mmHg; 95% CI, -1.79 to -1.15; P < 0.00001). But the BP-lowering effects of sodium-glucose cotransporter 2 inhibitors were more significant than those of DPP-4 inhibitors for both SBP (mean difference, 4.44 mmHg; 95% CI, 2.67-6.22; P < 0.00001) and DBP (mean difference, 2.15 mmHg; 95% CI, 1.08-3.21; P < 0.00001). No significant differences in BP changes were shown between DPP-4 inhibitors with other antidiabetic agents including glucagon-like peptide 1 receptor agonists, pioglitazone, sulphonylureas, metformin, and α-glucosidase inhibitors. DPP-4 inhibitors may exert modest BP-lowering effects compared with placebo or nontreatment for patients with T2DM, but no significant BP improvement was seen with this drug class when compared with other antidiabetic medications.
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Nakamura T, Iwanaga Y, Miyaji Y, Nohara R, Ishimura T, Miyazaki S. Cardiovascular efficacy of sitagliptin in patients with diabetes at high risk of cardiovascular disease: a 12-month follow-up. Cardiovasc Diabetol 2016; 15:54. [PMID: 27036865 PMCID: PMC4818390 DOI: 10.1186/s12933-016-0371-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 03/18/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Gliptins should have beneficial effects beyond glycemic control, potentially on the pathophysiology of cardiovascular (CV) diseases, with some basic studies demonstrating this possibility. However, we are yet to answer whether there are any direct CV effects in the clinical setting. We aimed to examine the beneficial effects of sitagliptin in Japanese patients with diabetes and high CV risk for 12 months. METHODS This was a prospective, multicenter, observational study of 205 patients with type 2 diabetes. All participants had more than one major CV risk factor and were treated with sitagliptin for 12 months. At 3 or 12 months, we examined the effects of treatment on glycemic control, CV function (by electrocardiography, echocardiography, and reactive hyperemia-peripheral arterial tonometry), and CV biomarkers. RESULTS Patients were predominantly elderly (68.8 ± 9.9 years) and male (71.5 %) and typically had more than three CV risk factors (79.2 %). Treatment with sitagliptin significantly reduced the hemoglobin A1c (HbA1c) level from 7.09 % ± 0.81 % at baseline to 6.67 % ± 0.69 % at 3 months and 6.68 % ± 0.73 % at 12 months (both P < 0.001). The reduction in HbA1c was also in tandem with the decrease in the level of high-sensitive C-reactive protein throughout the study. Independent of the change in HbA1c, sitagliptin reduced systolic (-7.0 ± 18.9 mmHg) and diastolic blood pressure (-5.1 ± 11.7 mmHg) at 12 months, and this was associated with a decrease in urinary albumin. In contrast, there were no beneficial effects on cardiac and endothelial function or on the levels of serum B-type natriuretic peptide, high-sensitive troponin T, and urinary 8-hydroxy-2'-deoxyguanosine. CONCLUSIONS In Japanese patients with diabetes and multiple CV risk factors, sitagliptin showed a decrease in blood pressure associated with an improvement in albuminuria in addition to glycemic control. TRIAL REGISTRATION UMIN000005663.
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Affiliation(s)
- Takashi Nakamura
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Kinki University, 377-2 Ohno-Higashi, Osakasayama, 589-8511, Japan
| | - Yoshitaka Iwanaga
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Kinki University, 377-2 Ohno-Higashi, Osakasayama, 589-8511, Japan
| | - Yuki Miyaji
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Kinki University, 377-2 Ohno-Higashi, Osakasayama, 589-8511, Japan
| | | | | | - Shunichi Miyazaki
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Kinki University, 377-2 Ohno-Higashi, Osakasayama, 589-8511, Japan.
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Betônico CCR, Titan SMO, Correa-Giannella MLC, Nery M, Queiroz M. Management of diabetes mellitus in individuals with chronic kidney disease: therapeutic perspectives and glycemic control. Clinics (Sao Paulo) 2016; 71:47-53. [PMID: 26872083 PMCID: PMC4732385 DOI: 10.6061/clinics/2016(01)08] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 11/26/2015] [Accepted: 11/26/2015] [Indexed: 12/16/2022] Open
Abstract
The purpose of this study was to evaluate the therapeutic options for diabetes treatment and their potential side effects, in addition to analyzing the risks and benefits of tight glycemic control in patients with diabetic kidney disease. For this review, a search was performed using several pre-defined keyword combinations and their equivalents: "diabetes kidney disease" and "renal failure" in combination with "diabetes treatment" and "oral antidiabetic drugs" or "oral hypoglycemic agents." The search was performed in PubMed, Endocrine Abstracts and the Cochrane Library from January 1980 up to January 2015. Diabetes treatment in patients with diabetic kidney disease is challenging, in part because of progression of renal failure-related changes in insulin signaling, glucose transport and metabolism, favoring both hyperglycemic peaks and hypoglycemia. Additionally, the decline in renal function impairs the clearance and metabolism of antidiabetic agents and insulin, frequently requiring reassessment of prescriptions. The management of hyperglycemia in patients with diabetic kidney disease is even more difficult, requiring adjustment of antidiabetic agents and insulin doses. The health team responsible for the follow-up of these patients should be vigilant and prepared to make such changes; however, unfortunately, there are few guidelines addressing the nuances of the management of this specific population.
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Affiliation(s)
- Carolina C R Betônico
- Universidade Oeste Paulista, Hospital Regional de Presidente Prudente, Divisão de Endocrinologia, Presidente Prudente/, SP, Brazil
| | - Silvia M O Titan
- Faculdade de Medicina da Universidade de São Paulo, Departamento de Medicina Interna, Divisão de Nefrologia
| | | | - Márcia Nery
- Divisão de Endocrinologia, São Paulo/, SP, Brazil
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Ryan G. Dipeptidyl peptidase-4 inhibitor use in patients with type 2 diabetes and cardiovascular disease or risk factors. Postgrad Med 2015; 127:842-54. [PMID: 26436470 DOI: 10.1080/00325481.2015.1095616] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Management of cardiovascular (CV) risk is an essential aspect of diabetes care, and acceptable CV risk is a requirement for antidiabetes medications. Dipeptidyl peptidase-4 (DPP-4) inhibitors effectively reduce glycated hemoglobin, with a low risk of hypoglycemia and weight gain. The purpose of this review is to discuss the use of DPP-4 inhibitors in patients with type 2 diabetes mellitus (T2DM) and CV disease or risk factors. METHODS A PubMed search (January 2013-June 2015) was conducted to identify prospective trials, meta-analyses, pooled analyses and cohort studies evaluating CV outcomes with DPP-4 inhibitors. RESULTS Meta-analyses, pooled analyses and retrospective cohort studies in patients with T2DM suggest no increased CV risk and possible CV benefit compared with some antidiabetes medications. The three published, long-term, prospective, randomized, double-blind CV outcomes trials in patients with CV disease or risk factors found no increased rate of major CV events in patients treated with alogliptin, saxagliptin or sitagliptin versus placebo as add-on to standard-of-care. However, the analysis of the components of the secondary end point of the saxagliptin study showed an increased number of hospitalizations for heart failure (HF) in treated patients versus placebo. A post hoc analysis of the alogliptin study showed no increase in HF hospitalization in treated patients with a history of HF versus placebo, but did show an increase in alogliptin-treated patients with no baseline HF history. Sitagliptin showed no increased risk for HF hospitalization versus placebo in the overall cohort. Two CV outcomes trials for linagliptin are ongoing. CONCLUSION The majority of available data from CV outcomes trials suggest a neutral effect of DPP-4 inhibitors on major CV events.
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Affiliation(s)
- Gina Ryan
- a Mercer University, College of Pharmacy , Atlanta, GA 30341, USA
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Fisman EZ, Tenenbaum A. Antidiabetic treatment with gliptins: focus on cardiovascular effects and outcomes. Cardiovasc Diabetol 2015; 14:129. [PMID: 26415691 PMCID: PMC4587723 DOI: 10.1186/s12933-015-0294-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 09/21/2015] [Indexed: 12/11/2022] Open
Abstract
The traditional oral pharmacological therapy for type 2 diabetes mellitus (T2DM) has been based on the prescription of metformin, a biguanide, as first line antihyperglycemic agent world over. It has been demonstrated that after 3 years of treatment, approximately 50 % of diabetic patients could achieve acceptable glucose levels with monotherapy; but by 9 years this had declined to only 25 %. Therefore, the implementation of a combined pharmacological therapy acting via different pathways becomes necessary, and its combination with a compound of the sulfonylurea group was along decades the most frequently employed prescription in routine clinical practice. Meglitinides, glitazones and alpha-glucosidase inhibitors were subsequently developed, but the five mentioned groups of oral antihyperglycemic agents are associated with variable degrees of undesirable or even severe cardiovascular events. The gliptins—also called dipeptidyl peptidase 4 (DPP4) inhibitors—are an additional group of antidiabetic compounds with increasing clinical use. We review the status of the gliptins with emphasis on their capabilities to positively or negatively affect the cardiovascular system, and their potential involvement in major adverse cardiovascular events (MACE). Alogliptin, anagliptin, linagliptin, saxagliptin, sitagliptin, teneligliptin and vildagliptin are the compounds currently in clinical use. Regardless differences in chemical structure and metabolic pathways, gliptins as a group exert favorable changes in experimental models. These changes, as an almost general rule, include improved endothelial function, reduction of inflammatory markers, oxidative stress ischemia/reperfusion injury and atherogenesis. In addition, increased adiponectin levels and modest decreases in lipidemia and blood pressure were reported. In clinical settings, several trials—notably the longer one, employing sitagliptin, with a mean follow-up period of 3 years—did not show an increased risk for ischemic events. Anyway, it should be emphasized that the encouraging results from basic science were not yet translated into clinical evidence, probably due the multiple and pleiotropic enzymatic effects of DPP4 inhibition. Moreover, when employing saxagliptin, while the drug was not associated with an augmented risk for ischemic events, it should be pinpointed that the rate of hospitalization for heart failure was significantly increased. Gliptins as a group constitute a widely accepted therapy for the management of T2DM, usually as a second-line medication. Nonetheless, for the time being, a definite relationship between gliptins treatment and improved cardiovascular outcomes remains uncertain and needs yet to be proven.
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Affiliation(s)
- Enrique Z Fisman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, 69978, Tel Aviv, Israel. .,Cardiovascular Diabetology Research Foundation, 58484, Holon, Israel.
| | - Alexander Tenenbaum
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, 69978, Tel Aviv, Israel. .,Cardiovascular Diabetology Research Foundation, 58484, Holon, Israel. .,Cardiac Rehabilitation Institute, Sheba Medical Center, 52621, Tel Hashomer, Israel.
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Abstract
Asia has a growing diabetic population. Linagliptin, a member of dipeptidyl peptidase-4 inhibitor class, is unique in its nonlinear pharmacokinetics with the characteristics of rapid attainment of steady state, little accumulation, predominantly nonrenal route of elimination, prolonged terminal half-life, and sustained inhibition of dipeptidyl peptidase-4 enzyme. No clinically relevant difference in pharmacokinetics was observed between Asians and non-Asians. The management of type 2 diabetes is increasingly challenging with the progression of disease, especially with the requirements of minimal hypoglycemia, weight gain, fluid retention, and other adverse effects. Linagliptin was efficacious and well-tolerated in Asian type 2 diabetes patients with or without renal or hepatic dysfunctions, comparable to that in Caucasians. This review will focus on the usage of linagliptin in clinical studies in Asians.
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Affiliation(s)
- Chu-Qing Cao
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Institute of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Yu-Fei Xiang
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Institute of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Zhi-Guang Zhou
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Institute of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
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Aroor AR, Sowers JR, Jia G, DeMarco VG. Pleiotropic effects of the dipeptidylpeptidase-4 inhibitors on the cardiovascular system. Am J Physiol Heart Circ Physiol 2015; 307:H477-92. [PMID: 24929856 DOI: 10.1152/ajpheart.00209.2014] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Dipeptidylpeptidase-4 (DPP-4) is a ubiquitously expressed transmembrane protein that removes NH2-terminal dipeptides from various substrate hormones, chemokines, neuropeptides, and growth factors. Two known substrates of DPP-4 include the incretin hormones glucagon-like peptide-1 (GLP-1) and gastric inhibitory peptide, which are secreted by enteroendocrine cells in response to postprandial hyperglycemia and account for 60–70% of postprandial insulin secretion. DPP-4 inhibitors (DPP-4i) block degradation of GLP-1 and gastric inhibitory peptide, extend their insulinotropic effect, and improve glycemia. Since 2006, several DPP-4i have become available for treatment of type 2 diabetes mellitus. Clinical trials confirm that DPP-4i raises GLP-1 levels in plasma and improves glycemia with very low risk for hypoglycemia and other side effects. Recent studies also suggest that DPP-4i confers cardiovascular and kidney protection, beyond glycemic control, which may reduce the risk for further development of the multiple comorbidities associated with obesity/type 2 diabetes mellitus, including hypertension and cardiovascular disease (CVD) and kidney disease. The notion that DPP-4i may improve CVD outcomes by mechanisms beyond glycemic control is due to both GLP-1-dependent and GLP-1-independent effects. The CVD protective effects by DPP-4i result from multiple factors including insulin resistance, oxidative stress, dyslipidemia, adipose tissue dysfunction, dysfunctional immunity, and antiapoptotic properties of these agents in the heart and vasculature. This review focuses on cellular and molecular mechanisms mediating the CVD protective effects of DPP-4i beyond favorable effects on glycemic control.
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Thrasher J, Kountz DS, Crowe S, Woerle HJ, von Eynatten M. Efficacy and safety of the dipeptidyl peptidase-4 inhibitor linagliptin in black/African American patients with type 2 diabetes: Pooled analysis from eight Phase III trials. Postgrad Med 2015; 127:419-28. [PMID: 25840727 DOI: 10.1080/00325481.2015.1027132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 03/05/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND The prevalence of type 2 diabetes in black/African Americans from North and South America is high; yet data evaluating antidiabetic agents in this population is scarce. To address this gap, we pooled data from the clinical development program for linagliptin. METHODS A retrospective pooled analysis of eight completed randomized, placebo-controlled Phase III trials of linagliptin identified 336 patients with type 2 diabetes who self-identified their ethnicity as black or African American. Participants received linagliptin (n = 173, 5 mg/day) or placebo (n = 163) as monotherapy, or as add-on to other antidiabetic agents, including insulin. The primary end point was the change in glycated hemoglobin (HbA1c) from baseline to week 18 or 24. RESULTS The placebo-adjusted mean change (95% confidence interval [CI]) in HbA1c from baseline was -0.69% (-0.92 to -0.46; p < 0.0001) at week 18 (eight trials), and -0.64% (-0.90 to -0.39; p < 0.0001) at week 24 (six trials). The placebo-adjusted mean change (95% CI) in fasting plasma glucose from baseline was -11.7 mg/dL (-23.1 to -0.3; p = 0.0446) at week 18 and -14.7 mg/dL (-25.7 to -3.8; p = 0.0087) at week 24. Incidence of investigator-defined hypoglycemia was similar between the two groups (linagliptin, 12.1%; placebo, 11.7%). Overall, the safety profile of linagliptin in this patient group was comparable to that of placebo, with comparable incidence of adverse events; linagliptin was weight-neutral in this patient population. CONCLUSION Linagliptin provided clinically significant improvements in glycemic control without increased risk of hypoglycemia and without weight gain, representing a useful type 2 diabetes therapy option for the black/African American population.
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Rosenstock J, Marx N, Neubacher D, Seck T, Patel S, Woerle HJ, Johansen OE. Cardiovascular safety of linagliptin in type 2 diabetes: a comprehensive patient-level pooled analysis of prospectively adjudicated cardiovascular events. Cardiovasc Diabetol 2015; 14:57. [PMID: 25990013 PMCID: PMC4465456 DOI: 10.1186/s12933-015-0215-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 04/27/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The cardiovascular (CV) safety of linagliptin was evaluated in subjects with type 2 diabetes (T2DM). METHODS Pre-specified patient-level pooled analysis of all available double-blind, randomized, controlled trials, ≥ 12 weeks' duration (19 trials, 9459 subjects) of linagliptin versus placebo/active treatment. Primary end point: composite of prospectively adjudicated CV death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization for unstable angina (4P-MACE). Hospitalization for congestive heart failure (CHF) was also evaluated; adjudication of CHF was introduced during the phase 3 program (8 trials; 3314 subjects). 4P-MACE was assessed in placebo-controlled trials (subgroup of 18 trials; 7746 subjects). Investigator-reported events suggestive of CHF from 24 placebo-controlled trials (including trials <12 weeks' duration, 8778 subjects) were also analyzed. RESULTS 5847 patients received linagliptin (5 mg: 5687, 10 mg: 160) and 3612 comparator (glimepiride: 775, voglibose: 162, placebo: 2675); cumulative exposure, 4421.3 and 3254.7 patient-years, respectively. 4P-MACE incidence rates: 13.4 per 1000 patient-years, linagliptin (60 events), 18.9, total comparators (62 events); overall hazard ratio (HR), 0.78 (95% confidence interval [CI], 0.55-1.12). HR for adjudicated hospitalization for CHF (n = 21): 1.04 (0.43-2.47). For placebo-controlled trials, 4P-MACE incidence rates: 14.9 per 1000 patient-years, linagliptin (43 events), 16.4, total comparators (29 events); overall HR, 1.09 (95% CI, 0.68-1.75). Occurrence of investigator-reported events suggestive of CHF was low for linagliptin- (26 events, 0.5%; serious: 16 events, 0.3%) and placebo-treated (8 events, 0.2%; serious: 6 events, 0.2%) patients. CONCLUSIONS Linagliptin is not associated with increased CV risk versus pooled active comparators or placebo in patients with T2DM.
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Affiliation(s)
- Julio Rosenstock
- Dallas Diabetes and Endocrine Center at Medical City, Dallas, TX, USA.
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany.
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Zhong J, Maiseyeu A, Davis SN, Rajagopalan S. DPP4 in cardiometabolic disease: recent insights from the laboratory and clinical trials of DPP4 inhibition. Circ Res 2015; 116:1491-504. [PMID: 25858071 PMCID: PMC4394189 DOI: 10.1161/circresaha.116.305665] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The discovery of incretin-based medications represents a major therapeutic advance in the pharmacological management of type 2 diabetes mellitus (T2DM), as these agents avoid hypoglycemia, weight gain, and simplify the management of T2DM. Dipeptidyl peptidase-4 (CD26, DPP4) inhibitors are the most widely used incretin-based therapy for the treatment of T2DM globally. DPP4 inhibitors are modestly effective in reducing HbA1c (glycated hemoglobin) (≈0.5%) and while these agents were synthesized with the understanding of the role that DPP4 plays in prolonging the half-life of incretins such as glucagon-like peptide-1 and gastric inhibitory peptide, it is now recognized that incretins are only one of many targets of DPP4. The widespread expression of DPP4 on blood vessels, myocardium, and myeloid cells and the nonenzymatic function of CD26 as a signaling and binding protein, across a wide range of species, suggest a teleological role in cardiovascular regulation and inflammation. Indeed, DPP4 is upregulated in proinflammatory states including obesity, T2DM, and atherosclerosis. Consistent with this maladaptive role, the effects of DPP4 inhibition seem to exert a protective role in cardiovascular disease at least in preclinical animal models. Although 2 large clinical trials suggest a neutral effect on cardiovascular end points, current limitations of performing trials in T2DM over a limited time horizon on top of maximal medical therapy must be acknowledged before rendering judgment on the cardiovascular efficacy of these agents. This review will critically review the science of DPP4 and the effects of DPP4 inhibitors on the cardiovascular system.
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Affiliation(s)
- Jixin Zhong
- From the Divisions of Cardiovascular Medicine and Endocrinology, University of Maryland, Baltimore
| | - Andrei Maiseyeu
- From the Divisions of Cardiovascular Medicine and Endocrinology, University of Maryland, Baltimore
| | - Stephen N Davis
- From the Divisions of Cardiovascular Medicine and Endocrinology, University of Maryland, Baltimore
| | - Sanjay Rajagopalan
- From the Divisions of Cardiovascular Medicine and Endocrinology, University of Maryland, Baltimore.
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Ahmed HA, May DW, Fagan SC, Segar L. Vascular Protection with Dipeptidyl Peptidase-IV inhibitors in Diabetes: Experimental and Clinical Therapeutics. Pharmacotherapy 2015; 35:277-97. [DOI: 10.1002/phar.1547] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Heba A. Ahmed
- Program in Clinical and Experimental Therapeutics; Department of Clinical and Administrative Pharmacy and Division of Experience Programs; College of Pharmacy; University of Georgia; Augusta Georgia
- Center for Pharmacy and Experimental Therapeutics; Medical College of Georgia; Georgia Regents University; Augusta Georgia
| | - Dianne W. May
- Program in Clinical and Experimental Therapeutics; Department of Clinical and Administrative Pharmacy and Division of Experience Programs; College of Pharmacy; University of Georgia; Augusta Georgia
- Center for Pharmacy and Experimental Therapeutics; Medical College of Georgia; Georgia Regents University; Augusta Georgia
| | - Susan C. Fagan
- Program in Clinical and Experimental Therapeutics; Department of Clinical and Administrative Pharmacy and Division of Experience Programs; College of Pharmacy; University of Georgia; Augusta Georgia
- Center for Pharmacy and Experimental Therapeutics; Medical College of Georgia; Georgia Regents University; Augusta Georgia
| | - Lakshman Segar
- Program in Clinical and Experimental Therapeutics; Department of Clinical and Administrative Pharmacy and Division of Experience Programs; College of Pharmacy; University of Georgia; Augusta Georgia
- Center for Pharmacy and Experimental Therapeutics; Medical College of Georgia; Georgia Regents University; Augusta Georgia
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Cook W, Minervini G, Bryzinski B, Hirshberg B. Saxagliptin efficacy and safety in patients with type 2 diabetes mellitus stratified by cardiovascular disease history and cardiovascular risk factors: analysis of 3 clinical trials. Postgrad Med 2015; 126:19-32. [PMID: 25414932 DOI: 10.3810/pgm.2014.10.2818] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To test the effectiveness and safety of saxagliptin 5 mg/d in patients with type 2 diabetes mellitus (T2DM) with and without history of cardiovascular disease (CVD) or cardiovascular (CV) risk factors. METHODS The authors conducted a post hoc analysis of data from 3 randomized studies that compared saxagliptin versus placebo as initial combination therapy with metformin for 24 weeks (N = 648) and versus placebo as an add-on to insulin with and without metformin for 24 weeks (N = 455), and assessed noninferiority to glipizide as an add-on to metformin for 52 weeks (N = 858). Efficacy outcomes were the adjusted mean change from baseline in glycated hemoglobin (HbA1c) level, fasting plasma glucose concentration, and body weight and the proportion of patients achieving an HbA1c level < 7%. Pairwise comparisons were performed in subgroups with 1) history/no history of CVD, 2) ≥ 2 versus 0 to 1 CV risk factors, 3) hypertension/no hypertension, and 4) statin use/no statin use. Adverse events (AE) and hypoglycemia were monitored. RESULTS In the initial combination therapy study, reductions in HbA1c level from baseline were greater with saxagliptin versus placebo in all subgroups (difference [saxagliptin - placebo], -0.38% to -0.67%). In the add-on to insulin ± metformin study, differences in adjusted mean change in HbA1c level versus placebo ranged from -0.23% to -0.58% across subgroups. In the noninferiority to glipizide study, adjusted mean changes in HbA1c level were comparable between saxagliptin and glipizide, across subgroups (difference, 0.08%-0.21%). No evidence suggested clinically relevant treatment-by-subgroup interactions in pairwise comparison. Incidences of ≥ 1 AE were comparable across subgroups. Incidences of confirmed hypoglycemia with saxagliptin were 0 in both metformin add-on studies and 1.2% to 7.8% with saxagliptin + insulin ± metformin. CONCLUSION In patients with T2DM, saxagliptin 5 mg/d was similarly effective in improving glycemic control, with an AE profile similar to that of placebo, irrespective of CVD history, number of CV risk factors, hypertension, or statin use. TRIAL REGISTRATION www.ClinicalTrials.gov identifiers: NCT00327015, NCT00575588, NCT00757588.
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Koibuchi N, Hasegawa Y, Katayama T, Toyama K, Uekawa K, Sueta D, Kusaka H, Ma M, Nakagawa T, Lin B, Kim-Mitsuyama S. DPP-4 inhibitor linagliptin ameliorates cardiovascular injury in salt-sensitive hypertensive rats independently of blood glucose and blood pressure. Cardiovasc Diabetol 2014; 13:157. [PMID: 25471116 PMCID: PMC4255443 DOI: 10.1186/s12933-014-0157-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 11/14/2014] [Indexed: 12/21/2022] Open
Abstract
Background It remains to be elucidated whether dipeptidylpeptidase-4 (DPP-4) inhibitor can ameliorate cardiovascular injury in salt-sensitive hypertension. The present study was undertaken to test our hypothesis that linagliptin, a DPP-4 inhibitor, administration initiated after onset of hypertension and cardiac hypertrophy can ameliorate cardiovascular injury in Dahl salt-sensitive hypertensive rats (DS rats). Methods High-salt loaded DS rats with established hypertension and cardiac hypertrophy were divided into two groups, and were orally given (1) vehicle or (2) linagliptin (3 mg/kg/day) once a day for 4 weeks, and cardiovascular protective effects of linagliptin in DS rats were evaluated. Results Linagliptin did not significantly affect blood pressure and blood glucose levels in DS rats. Linagliptin significantly lessened cardiac hypertrophy in DS rats, as estimated by cardiac weight and echocardiographic parameters. Linagliptin significantly ameliorated cardiac fibrosis, cardiac macrophage infiltration, and coronary arterial remodeling in DS rats. Furthermore, linagliptin significantly mitigated the impairment of vascular function in DS rats, as shown by the improvement of acetylcholine-induced or sodium nitroprusside-induced vascular relaxation by linagliptin. These cardiovascular protective effects of linagliptin were associated with the attenuation of oxidative stress, NADPH oxidase subunits, p67phox and p22 phox, and angiotensin-converting enzyme (ACE). Conclusions Our results provided the experimental evidence that linagliptin treatment initiated after the appearance of hypertension and cardiac hypertrophy protected against cardiovascular injury induced by salt-sensitive hypertension, independently of blood pressure and blood glucose. These beneficial effects of linagliptin seem to be attributed to the reduction of oxidative stress and ACE.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Shokei Kim-Mitsuyama
- Department of Pharmacology and Molecular Therapeutics, Kumamoto University Graduate School of Medical Sciences, 1-1-1 Honjo, Kumamoto 860-8556, Japan.
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Terawaki Y, Nomiyama T, Kawanami T, Hamaguchi Y, Takahashi H, Tanaka T, Murase K, Nagaishi R, Tanabe M, Yanase T. Dipeptidyl peptidase-4 inhibitor linagliptin attenuates neointima formation after vascular injury. Cardiovasc Diabetol 2014; 13:154. [PMID: 25407968 PMCID: PMC4240860 DOI: 10.1186/s12933-014-0154-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 10/30/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Recently, glucagon-like peptide-1 (GLP-1)-based therapy, including dipeptidyl peptidase-4 (DPP-4) inhibitors and GLP-1 receptor agonists, has emerged as one of the most popular anti-diabetic therapies. Furthermore, GLP-1-based therapy has attracted increased attention not only for its glucose-lowering ability, but also for its potential as a tissue-protective therapy. In this study, we investigated the vascular-protective effect of the DPP-4 inhibitor, linagliptin, using vascular smooth muscle cells (VSMCs). METHODS Six-week-old male C57BL/6 mice were divided into control (n =19) and linagliptin (3 mg/kg/day, n =20) treated groups. Endothelial denudation injuries were induced in the femoral artery at 8 weeks of age, followed by evaluation of neointima formation at 12 weeks. To evaluate cell proliferation of rat aortic smooth muscle cells, a bromodeoxyuridine (BrdU) incorporation assay was performed. RESULTS Linagliptin treatment reduced vascular injury-induced neointima formation, compared with controls (p <0.05). In these non-diabetic mice, the body weight and blood glucose levels did not change after treatment with linagliptin. Linagliptin caused an approximately 1.5-fold increase in serum active GLP-1 concentration, compared with controls. In addition, the vascular injury-induced increase in the oxidative stress marker, urinary 8-OHdG, was attenuated by linagliptin treatment, though this attenuation was not statistically significant (p =0.064). Moreover, linagliptin did not change the serum stromal cell-derived factor-1α (SDF-1α) or the serum platelet-derived growth factor (PDGF) concentration. However, linagliptin significantly reduced in vitro VSMC proliferation. CONCLUSION Linagliptin attenuates neointima formation after vascular injury and VSMC proliferation beyond the glucose-lowering effect.
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Affiliation(s)
- Yuichi Terawaki
- Department of Endocrinology and Diabetes Mellitus, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Takashi Nomiyama
- Department of Endocrinology and Diabetes Mellitus, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Takako Kawanami
- Department of Endocrinology and Diabetes Mellitus, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Yuriko Hamaguchi
- Department of Endocrinology and Diabetes Mellitus, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Hiroyuki Takahashi
- Department of Endocrinology and Diabetes Mellitus, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Tomoko Tanaka
- Department of Endocrinology and Diabetes Mellitus, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Kunitaka Murase
- Department of Endocrinology and Diabetes Mellitus, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Ryoko Nagaishi
- Department of Endocrinology and Diabetes Mellitus, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Makito Tanabe
- Department of Endocrinology and Diabetes Mellitus, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Toshihiko Yanase
- Department of Endocrinology and Diabetes Mellitus, School of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
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Karagiannis T, Boura P, Tsapas A. Safety of dipeptidyl peptidase 4 inhibitors: a perspective review. Ther Adv Drug Saf 2014; 5:138-46. [PMID: 25083269 DOI: 10.1177/2042098614523031] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Dipeptidyl peptidase 4 (DPP-4) inhibitors are a relatively new class of oral antihyperglycemic agent that enhance insulin secretion by reducing degradation of endogenous glucagon-like peptide 1. Currently, sitagliptin, vildagliptin, saxagliptin, linagliptin and alogliptin have been approved by the US Food and Drug Administration or the European Medicines Agency for use in patients with type 2 diabetes. Their glycemic efficacy has been well documented; however, data regarding their long-term safety are as yet inconclusive. While preclinical studies have indicated a potential cardioprotective effect of DPP-4 inhibitors, current clinical data from cardiovascular safety trials suggest a neutral effect on cardiovascular outcomes. Moreover, postmarketing experience has given rise to concerns about specific adverse events, including pancreatitis and hypersensitivity reactions. This review summarizes available evidence regarding safety of DPP-4 inhibitors. Overall, DPP-4 inhibitors appear to be a safe option for patients with type 2 diabetes. However, close pharmacovigilance is necessary to address the uncertainty regarding pancreas-related adverse events, while their potential impact on cardiovascular outcomes will be further elucidated after completion of more long-term studies.
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Affiliation(s)
| | - Panagiota Boura
- Second Medical Department, Aristotle University Thessaloniki, Greece
| | - Apostolos Tsapas
- Second Medical Department, Aristotle University Thessaloniki, Greece and Harris Manchester College, University of Oxford, UK
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Ott C, Raff U, Schmidt S, Kistner I, Friedrich S, Bramlage P, Harazny JM, Schmieder RE. Effects of saxagliptin on early microvascular changes in patients with type 2 diabetes. Cardiovasc Diabetol 2014; 13:19. [PMID: 24423149 PMCID: PMC3897922 DOI: 10.1186/1475-2840-13-19] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 01/11/2014] [Indexed: 01/21/2023] Open
Abstract
Background Patients with diabetes mellitus are at increased risk for microvascular complications. Early changes in microcirculation are characterized by hyperperfusion (e.g. in the retina and kidney) and increased pulse wave reflection leading to increased aortic pressure. We investigated the effects of the DPP-4-inhibitor saxagliptin on early retinal microvascular changes. Methods In this double-blind, controlled, cross-over trial 50 patients (without clinical signs of microvascular alterations) with type-2 diabetes (mean duration of 4 years) were randomized to receive placebo or 5 mg saxagliptin for 6 weeks. Retinal arteriolar structure and retinal capillary flow (RCF) at baseline and during flicker-light exposure was assessed by scanning laser Doppler flowmetry. Central hemodynamics were assessed by pulse wave analysis. Results Postprandial blood glucose (9.27 ± 0.4 versus 10.1 ± 0.4 mmol/L; p = 0.001) and HbA1c (6.84 ± 0.15 (51 ± 1.6) versus 7.10 ± 0.17% (54 ± 1.9 mmol/mol); p < 0.001) were significantly reduced with saxagliptin treatment compared to placebo. RCF was significantly reduced after treatment with saxagliptin (288 ± 13.2 versus 314 ± 14.1 AU; p = 0.033). This was most pronounced in a subgroup of patients (n = 32) with a fall in postprandial blood glucose (280 ± 12.1 versus 314 ± 16.6 AU; p = 0.011). No significant changes in RCF were seen during flicker-light exposure between placebo and saxagliptin, but the vasodilatory capacity increased two-fold with saxagliptin treatment. Central augmentation pressure tended to be lower after treatment with saxagliptin (p = 0.094), and central systolic blood pressure was significantly reduced (119 ± 2.3 versus 124 ± 2.3 mmHg; p = 0.038). Conclusions Our data suggest that treatment with saxagliptin for 6 weeks normalizes retinal capillary flow and improves central hemodynamics in type-2 diabetes. Trial registration The study was registered at (ID: NCT01319357).
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Affiliation(s)
| | | | | | | | | | | | | | - Roland E Schmieder
- Department of Nephrology and Hypertension, University of Erlangen-Nuremberg, Ulmenweg 18, Erlangen, Germany.
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Muskiet MHA, Smits MM, Morsink LM, Diamant M. The gut-renal axis: do incretin-based agents confer renoprotection in diabetes? Nat Rev Nephrol 2013; 10:88-103. [PMID: 24375052 DOI: 10.1038/nrneph.2013.272] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diabetic nephropathy is the leading cause of end-stage renal disease worldwide, and is associated with a high risk of cardiovascular morbidity and mortality. Intensive control of glucose levels and blood pressure is currently the mainstay of both prevention and treatment of diabetic nephropathy. However, this strategy cannot fully prevent the development and progression of diabetic nephropathy, and an unmet need remains for additional novel therapies. The incretin-based agents--agonists of glucagon-like peptide 1 receptor (GLP-1R) and inhibitors of dipeptidyl peptidase 4 (DPP-4), an enzyme that degrades glucagon-like peptide 1--are novel blood-glucose-lowering drugs used in the treatment of type 2 diabetes mellitus (T2DM). Therapeutic agents from these two drug classes improve pancreatic islet function and induce extrapancreatic effects that ameliorate various phenotypic defects of T2DM that are beyond glucose control. Agonists of GLP-1R and inhibitors of DPP-4 reduce blood pressure, dyslipidaemia and inflammation, although only GLP-1R agonists decrease body weight. Both types of incretin-based agents inhibit renal tubular sodium reabsorption and decrease glomerular pressure as well as albuminuria in rodents and humans. In rodents, incretin-based therapies also prevent onset of the morphological abnormalities of diabetic nephropathy.
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Affiliation(s)
- Marcel H A Muskiet
- Diabetes Centre, Department of Internal Medicine, VU University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - Mark M Smits
- Diabetes Centre, Department of Internal Medicine, VU University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - Linde M Morsink
- Diabetes Centre, Department of Internal Medicine, VU University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - Michaela Diamant
- Diabetes Centre, Department of Internal Medicine, VU University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
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von Websky K, Reichetzeder C, Hocher B. Linagliptin as add-on therapy to insulin for patients with type 2 diabetes. Vasc Health Risk Manag 2013; 9:681-94. [PMID: 24204157 PMCID: PMC3818026 DOI: 10.2147/vhrm.s40035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a highly prevalent, progressive disease that often is poorly controlled. The combination of an incretin-based therapy and insulin is a promising approach to optimize the management of glycemic control without hypoglycemia and weight gain. Linagliptin, a recently approved oral dipeptidyl peptidase-4 inhibitor, has a unique pharmacological profile. The convenient, once-daily dosing does not need adjustment in patients with hepatic and/or renal impairment. In clinical studies linagliptin shows an important reduction of blood glucose with an overall safety profile similar to that of placebo. So far, the combination of linagliptin and insulin has been tested in three major clinical studies in different populations. It has been shown that linagliptin is an effective and safe add-on therapy to insulin in patients with T2DM. The efficacy and safety of this combination was also shown in vulnerable, elderly T2DM patients and in patients with T2DM and renal impairment. Favorable effects regarding the counteraction of hypoglycemia make linagliptin especially interesting as an add-on therapy to insulin. This review aims to present the existing clinical studies on the efficacy and safety of linagliptin as add-on therapy to insulin in patients with T2DM in the context of current literature. Additionally, the possible advantages of linagliptin as an add-on therapy to insulin in relation to cardiovascular safety, patient-centered therapy and the prevention of hypoglycemia, are discussed.
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Affiliation(s)
- Karoline von Websky
- Institute of Nutritional Science, University of Potsdam, Potsdam-Rehbrücke, Germany
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Petrie JR. The cardiovascular safety of incretin-based therapies: a review of the evidence. Cardiovasc Diabetol 2013; 12:130. [PMID: 24011363 PMCID: PMC3847044 DOI: 10.1186/1475-2840-12-130] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 08/21/2013] [Indexed: 12/18/2022] Open
Abstract
Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in people with diabetes and therefore managing cardiovascular (CV) risk is a critical component of diabetes care. As incretin-based therapies are effective recent additions to the glucose-lowering treatment armamentarium for type 2 diabetes mellitus (T2D), understanding their CV safety profiles is of great importance. Glucagon-like peptide-1 (GLP-1) receptor agonists have been associated with beneficial effects on CV risk factors, including weight, blood pressure and lipid profiles. Encouragingly, mechanistic studies in preclinical models and in patients with acute coronary syndrome suggest a potential cardioprotective effect of native GLP-1 or GLP-1 receptor agonists following ischaemia. Moreover, meta-analyses of phase 3 development programme data indicate no increased risk of major adverse cardiovascular events (MACE) with incretin-based therapies. Large randomized controlled trials designed to evaluate long-term CV outcomes with incretin-based therapies in individuals with T2D are now in progress, with the first two reporting as this article went to press.
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Affiliation(s)
- John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK.
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