Efficacy and safety of insulin in type 2 diabetes: meta-analysis of randomised controlled trials

Practical therapeutic approach in the management of diabetes mellitus secondary to Cushing's syndrome, acromegaly and neuroendocrine tumours

Cushing's syndrome, acromegaly and neuroendocrine disorders are characterized by an excess of counterregulatory hormones, able to induce insulin resistance and glucose metabolism disorders at variable degrees and requiring immediate treatment, until patients are ready to undergo surgery. This review focuses on the management of diabetes mellitus in endocrine disorders related to an excess of counterregulatory hormones. Currently, the landscape of approved agents for treatment of diabetes is dynamic and is mainly patient-centred and not glycaemia-centred. In addition, personalized medicine is more and more required to provide a precise approach to the patient's disease. For this reason, we aimed to define a practical therapeutic algorithm for management of diabetes mellitus in patients with glucagonoma, pheochromocytoma, Cushing's syndrome and acromegaly, based on our practical experience and on the physiopathology of the specific endocrine disease taken into account. This document is addressed to all specialists who approach patients with diabetes mellitus secondary to endocrine disorders characterized by an excess of counterregulatory hormones, in order to take better care of these patients. Care and control of diabetes mellitus should be one of the primary goals in patients with an excess of counterregulatory hormones requiring immediate and aggressive treatment.

Ertugliflozin Delays Insulin Initiation and Reduces Insulin Dose Requirements in Patients With Type 2 Diabetes: Analyses From VERTIS CV

CONTEXT

VERTIS CV evaluated the cardiovascular safety of ertugliflozin in patients with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD).

OBJECTIVE

The aim of these analyses was to assess the insulin requirements of VERTIS CV patients over the trial duration.

METHODS

Patients received ertugliflozin 5 mg, 15 mg, or placebo once daily; mean follow-up was 3.5 years. Time to insulin initiation in patients who were insulin naïve at baseline, change in insulin dose in patients receiving baseline insulin, and hypoglycemia incidence in both patient groups were assessed.

RESULTS

In VERTIS CV, mean duration of type 2 diabetes was 13.0 years; glycated hemoglobin was 8.2%. Among 4348 (53%) insulin-naïve patients, the likelihood of insulin initiation was significantly reduced with ertugliflozin vs placebo (ertugliflozin 5 mg: hazard ratio [HR] 0.70, 95% CI 0.58-0.84; ertugliflozin 15 mg: HR 0.64, 95% CI 0.53-0.78). Time to insulin initiation was delayed with ertugliflozin; the estimated delay in reaching a 10% cumulative incidence of new insulin initiations vs placebo was 399 days with ertugliflozin 5 mg and 669 days with ertugliflozin 15 mg. Among 3898 (47%) patients receiving baseline insulin, the likelihood of requiring a ≥20% increase in insulin dose was significantly reduced with ertugliflozin vs placebo (ertugliflozin 5 mg: HR 0.62, 95% CI 0.52-0.75; ertugliflozin 15 mg: HR 0.51, 95% CI 0.41-0.62). The incidence of hypoglycemia events was not increased with ertugliflozin treatment.

CONCLUSION

In VERTIS CV patients, ertugliflozin reduced the likelihood of insulin initiation, delayed the time to insulin initiation by up to ∼1.8 years, and reduced insulin dose requirements vs placebo, without increasing hypoglycemia events.

Clinical pharmacology of antidiabetic drugs: What can be expected of their use?

The pharmacotherapy of type 2 diabetes mellitus (T2DM) has markedly evolved in the last two decades. Classical antidiabetic agents (sulphonylureas, metformin, insulin) are now in competition with new glucose-lowering medications. Alpha-glucosidase inhibitors and thiazolidinediones (glitazones) were not able to replace older agents, because of insufficient efficacy and/or poor tolerability/safety. In contrast, incretin-based therapies, both dipeptidyl peptidase-4 inhibitors (DPP-4is or gliptins, oral agents) and glucagon-like peptide-1 receptor agonists (GLP-1RAs, subcutaneous injections) are a major breakthrough in the management of T2DM. Because they are not associated with hypoglycaemia and weight gain, DPP-4is tend to replace sulphonylureas as add-on to metformin while GLP-1RAs tend to replace basal insulin therapy after failure of oral therapies. Furthermore, placebo-controlled cardiovascular outcome trials demonstrated neutrality for DPP-4is, but cardiovascular protection for GLP-1RAs in patients with T2DM at high cardiovascular risk. More recently sodium-glucose cotransporter 2 inhibitors (SGLT2is or gliflozins, oral agents) also showed cardiovascular protection, especially a reduction in hospitalization for heart failure, as well as a renal protection in patients with and without T2DM, at high cardiovascular risk, with established heart failure and/or with chronic kidney disease. Thus, GLP-1RAs and SGLT2is are now considered as preferred drugs in T2DM patients with or at high risk of atherosclerotic cardiovascular disease whereas SGLT2is are more specifically recommended in patients with or at risk of heart failure and renal (albuminuric) disease. The management of T2DM is moving from a glucocentric approach to a broader strategy focusing on all risk factors, including overweight/obesity, and to an organ-disease targeted personalized approach.

Diabetes Management and Outcomes among Patients with Type 2 Diabetes Attending a Renal Service

Background

Patients with comorbid type 2 diabetes mellitus (T2DM) and renal disease, particularly those treated with insulin, often require complex pharmacological treatment and management of other diabetes complications.

Aims

To assess the achievement of metabolic targets and compare the current management of renal service attenders with insulin- and noninsulin-treated T2DM.

Methods

Single-centre retrospective cross-sectional study involving medical record review of patients with T2DM aged ≥18 years who visited a metropolitan renal outpatient clinic in 2017. Univariable analysis and multivariable logistic regression were used to identify factors associated with insulin treatment.

Results

Among 268 patients (45.5% insulin-treated), mean HbA1c was higher in insulin-treated vs. noninsulin-treated patients (8.0 ± 1.8% (64 mmol/mol) vs. 6.8 ± 1.2% (51 mmol/mol), p < 0.001). Significantly fewer insulin-treated patients had HbA1c ≤ 7.0% (53 mmol/mol; 31.8% vs. 69.3%, p < 0.001). More insulin-treated patients had ischaemic heart disease (46.7% vs. 33.6%, p = 0.028), diabetic foot disease (15.6% vs. 4.8%, p = 0.003), retinopathy (40.2% vs. 11.0%, p < 0.001), and emergency attendance for severe hypoglycaemia (3.8% vs. 0% p = 0.042). Insulin treatment was more associated with chronic kidney disease stages 4-5 (adjusted odds ratio (aOR) 2.41, 95% CI 1.07-5.43), retinopathy (aOR 3.10, 95% CI 1.04-9.27), and podiatry review (aOR 5.06, 95% CI 1.20-21.38). Only 38 (14.2%) individuals were seen by a colocated public multidisciplinary diabetes service in 2017.

Conclusions

Renal clinic attenders with T2DM, particularly if insulin-treated, remained at increased risk of diabetes-related complications, including severe hypoglycaemia, with limited input from the colocated hospital diabetes team. Approaches to increase coordination of diabetes care among renal patients should be investigated.

Effects of insulin on cardiovascular events and all-cause mortality in patients with type 2 diabetes: A meta-analysis of randomized controlled trials

AIM

In 2019, the Italian Society of Diabetology and the Italian Association of Clinical Diabetologists nominated an expert panel to develop guidelines for drug treatment of type 2 diabetes. This expert panel, after identifying the effects of glucose-lowering agents on major adverse cardiovascular events (MACEs), all-cause mortality, and hospitalization for heart failure (HHF) as critical outcomes, decided to perform a systematic review and meta-analysis on the effect of insulin with this respect.

DATA SYNTHESIS

A MEDLINE database search was performed to identify all RCTs, up to June 1st, 2021, with duration≥52 weeks, in which insulin was compared with either placebo or active comparators. The principal endpoints were MACE and HHF (restricted for RCT reporting MACEs within their outcomes), all-cause mortality (irrespective of the inclusion of MACEs among the pre-specified outcomes). Mantel-Haenszel odds ratio (MH-OR) with 95% Confidence Interval (95% CI) was calculated for all the endpoints considered. Six RCTs (enrolling 8091 patients and 10,139 in the insulin and control group, respectively) were included in the analysis for MACEs and HF, and 18 in that for all-cause mortality (9760 and 11,694 patients in the insulin and control group, respectively). Treatment with insulin neither significantly increased nor reduced the risk of MACE, all-cause mortality, and HHF in comparison with placebo/active comparators (MH-OR: 1.09, 95% CI 0.97-1.23; 0.99, 95% CI 0.91, 1.08; and 0.90, 95% CI 0.78, 1.04, respectively).

CONCLUSIONS

This meta-analysis showed no significant effects of insulin on incident MACE, all-cause mortality, and HHF.

Association between changes in body weight and cardiovascular disease risk factors among obese Japanese patients with type 2 diabetes

Aims/Introduction

We aimed to assess the association between bodyweight reduction and cardiovascular disease risk factors, and to identify the minimum bodyweight reduction associated with significant improvement in cardiovascular disease risk factors among obese Japanese patients with type 2 diabetes.

Materials and Methods

The cohort comprised 1,753 patients with type 2 diabetes and body mass index ≥25 kg/m², who visited our clinic between 2013 and 2016. Multivariable linear regression analysis was carried out to assess the relationship between bodyweight changes and glycated hemoglobin A1c, serum lipids and blood pressure. Analyses of covariance were carried out to compare mean changes in cardiovascular disease risk factors across six groups of bodyweight change, <−5%, −5% to <−3%, −3% to <−1%, −1% to <1% (reference), 1% to <3% and ≥3%.

Results

Log‐transformed bodyweight change had a significantly positive relationship with log‐transformed glycated hemoglobin A1c, triglycerides, low‐density lipoprotein cholesterol and systolic blood pressure changes, and a negative relationship with high‐density lipoprotein cholesterol, after adjusting for sex, age, duration of diabetes, body mass index, use of glucose‐lowering, lipid‐lowering and antihypertensive agents, and changes in the use of these medications. A mean change in glycated hemoglobin A1c was significantly improved only in the <−5% group compared with the reference. Mean changes in triglycerides were improved in all groups, and significantly in the <−5% group.

Conclusions

Bodyweight change was significantly associated with cardiovascular disease risk factor changes, and >5% bodyweight reduction was associated with improved glycated hemoglobin A1c.

Not All Type-2-Diabetes Patients Increase Body Mass Index After Initiating Insulin: Results of Latent Class Analysis from the DPV Registry

Background: Is insulin initiation linked to increasing body mass index (BMI) in all patients with type-2-diabetes (T2D)? To determine distinct longitudinal patterns of BMI change over time. Materials and Methods: 5057 patients with T2D (55% males, median BMI [IQR]: 30.0 [26.9-33.3] kg/m²) aged ≥40 years at diabetes diagnosis and with ≥2 years of follow-up after insulin initiation irrespective of previous or concurrent use of metformin/dipeptidyl peptidase-4-inhibitor from the multicenter prospective diabetes registry DPV were studied. To identify subgroups following a similar pattern of BMI change after insulin initiation, longitudinal group-based trajectory modeling was applied. Multinomial logistic regression was then used to analyze covariates associated with group membership. Results: Three heterogeneous groups with either relevant BMI increase (delta-BMI: +4.0 kg/m² after 2 years; 12% of patients); slight BMI increase (+0.4 kg/m²; 80%); or BMI decrease (-3.2 kg/m²; 8%) were identified. Patients with older age [OR (95% CI): 1.37 (1.11-1.69)] and obesity [2.05 (1.65-2.55)] before insulin start were more often in the BMI decreasing group, and less often in the BMI increasing class [0.80 (0.67-0.95); 0.82 (0.69-0.98)]. A worse HbA1c both at insulin start and during follow-up [1.90 (1.60-2.26); 1.17 (1.07-1.27)], a higher insulin dose [1.67 (1.33-2.10)], and severe hypoglycemic events [2.38 (1.60-3.53)] after insulin initiation were all linked with higher odds of belonging to the BMI increasing trajectory. Conclusions: Patient heterogeneity with respect to weight gain after initiation of insulin therapy in adult T2D was detected by an objective computer algorithm. Older people with obesity should not defer from insulin use due to fear of weight gain.

The effects of insulin therapy on maternal blood pressure and weight in women with gestational diabetes mellitus

Background

Although insulin therapy achieves effective glycemic control, it may aggravate hyperinsulinemia. Nonetheless the benefits of insulin as first-line treatment for women with GDM are controversial. This work aimed to investigate the effect of insulin on maternal GDM.

Methods

This retrospective cohort study recruited 708 women with GDM of whom 616 underwent lifestyle intervention and 92 were prescribed insulin therapy. Differences in variables between the two groups were analyzed by univariate analysis and multivariate analysis. Propensity score matching was used to control for age, pre-pregnancy BMI, time and BP at GDM diagnosis, and family history of diabetes and hypertension. Paired sample test was applied to evaluate the changes in BP after intervention in the two groups of women.

Results

There was no significant difference in mode of delivery, newborn weight or incidence of macrosomia between women prescribed insulin and those who adopted lifestyle modifications. Insulin therapy was associated with a slight increase in maternal weight compared with the lifestyle intervention group and was attributed to short-term treatment (about 12 weeks). In addition, insulin therapy remarkably increased maternal blood pressure, an effect that persisted after matching age, pre-pregnancy BMI, time and BP at GDM diagnosis, and family history of diabetes and hypertension. Between commencing insulin therapy and delivery, systolic blood pressure significantly increased by 6mmHg (P = 0.015) and diastolic blood pressure by 9 mmHg (P < 0.001). Increase in BP was significantly higher in the insulin group compared with the lifestyle intervention group (P < 0.001). Logistic regression analysis with enter selection confirmed that insulin therapy was closely correlated with development of gestational hypertension (GH).

Conclusions

This work suggested that short-term insulin therapy for GDM was associated with a slight increase in maternal weight but a significant risk of increasing maternal blood pressure.

Renal hemodynamic effects differ between antidiabetic combination strategies: randomized controlled clinical trial comparing empagliflozin/linagliptin with metformin/insulin glargine

BACKGROUND

Type 2 diabetes causes cardio-renal complications and is treated with different combination therapies. The renal hemodynamics profile of such combination therapies has not been evaluated in detail.

METHODS

Patients (N = 97) with type 2 diabetes were randomized to receive either empagliflozin and linagliptin (E+L group) or metformin and insulin glargine (M+I group) for 3 months. Renal hemodynamics were assessed with para-aminohippuric acid and inulin for renal plasma flow (RPF) and glomerular filtration rate (GFR). Intraglomerular hemodynamics were calculated according the Gomez´ model.

RESULTS

Treatment with E+L reduced GFR (p = 0.003), but RPF remained unchanged (p = 0.536). In contrast, M+I not only reduced GFR (p = 0.001), but also resulted in a significant reduction of RPF (p < 0.001). Renal vascular resistance (RVR) decreased with E+L treatment (p = 0.001) but increased with M+I treatment (p = 0.001). The changes in RPF and RVR were different between the two groups (both p_adjust < 0.001). Analysis of intraglomerular hemodynamics revealed that E+L did not change resistance of afferent arteriole (R_A) (p = 0.116), but diminished resistance of efferent arterioles (R_E) (p = 0.001). In M+I group R_A was increased (p = 0.006) and R_E remained unchanged (p = 0.538). The effects on R_A (p_adjust < 0.05) and on R_E (p_adjust < 0.05) differed between the groups.

CONCLUSIONS

In patients with type 2 diabetes and preserved renal function treatment with M+I resulted in reduction of renal perfusion and increase in vascular resistance, in contrast to treatment with E+I that preserved renal perfusion and reduced vascular resistance. Moreover, different underlying effects on the resistance vessels have been estimated according to the Gomez model, with M+I increasing R_A and E+L predominantly decreasing R_E, which is in contrast to the proposed sodium-glucose cotransporter 2 inhibitor effects.

TRIAL REGISTRATION

The study was registered at www.clinicaltrials.gov (NCT02752113) on April 26, 2016.

Course of body weight before and after the initiation of insulin therapy in type 2 diabetes mellitus: Retrospective inception cohort study (ZODIAC 58)

Aims

The aim of this study was to explore the effect of insulin treatment initiation on weight by taking weight change prior to initiation into account.

Materials and methods

We performed an observational retrospective inception cohort study, concerning Dutch primary care. We identified all patients that initiated insulin treatment (n = 7967) and individually matched patients with a reference patient (n = 5213 pairs). We obtained estimated mean weight changes in the five years prior to five years post insulin therapy. We applied linear regression analysis on weight change in the first year after insulin therapy (T0 to T+1), with matched group as primary determinant adjusted for pre-insulin weight change and additional covariates.

Results

Estimated mean weight increased in the five consecutive years prior to insulin therapy (-0.23 kg in year T-5 to T-4, 0.01 kg in year T-4 to T-3, 0.07 kg in year T-3 to T-2, 0.24 kg in year T-2 to T-1, and 0.46 kg in year T-1 to T0) and continued to increase in the first year after, that is T0 to T+1, at a slightly lower rate (0.31 ± 3.9 kg). Pre-insulin weight change had the highest explained variance and was inversely and independently associated with weight change (p < .001). Starting insulin was associated with weight increase, independent of pre-insulin weight change (β-adjusted 1.228, p < .001). Stratification revealed that despite having a more or less similar baseline BMI, patients with substantial weight increase showed higher estimated mean BMI's followed by weight loss pre-insulin. In matched references, estimated mean weight changes were negative in all years concerning the study period, indicating consistent weight loss.

Conclusions

Initiation of insulin therapy was independently associated with weight increase; however, overall effect on weight was small and subject to substantial variation. Pre-insulin weight change is identified as a relatively strong inverse determinant of weight change after insulin initiation.

All-cause mortality and cardiovascular safety of basal insulin treatment in patients with type 2 diabetes mellitus: A systematic review with meta-analysis and trial sequential analysis

AIM

To evaluate the risk of all-cause and cardiovascular mortality, acute myocardial infarction, and stroke associated with insulin treatment in patients with type 2 diabetes.

METHODS

A systematic review with meta-analysis of randomized clinical trials (RCTs) was performed. EMBASE, Cochrane, and PubMed databases were searched for RCTs reporting mortality or cardiovascular events and comparing basal insulin to any treatment in patients with type 2 diabetes. Data were summarized with Mantel-Haenzel relative risk (RR). Trial sequential analysis (TSA) was used to evaluate the reliability of the results considering a 20% relative risk difference between treatments. PROSPERO Registry: CRD42018087336.

RESULTS

In total, 2351 references were identified, and 26 studies (24348 patients) were included. Most studies evaluated glargine insulin (69%), compared insulin to GLP-1 analogs (57%), and evaluated add-on therapy with metformin (77%). Insulin was not associated with increased all-cause mortality (RR 0.99; 95% confidence interval (CI) 0.92-1.06), cardiovascular mortality (RR 1.01; 95% CI 0.91-1.13), myocardial infarction (RR 1.02; 95% CI 0.92-1.15), or stroke (RR 0.87; 95% CI 0.68-1.12). Insulin treatment increased severe hypoglycemia risk (RR 2.98; 95% CI 2.47-3.61). All analyses had low statistical heterogeneity. TSA confirmed these findings: optimal sample size (myocardial infarction), futility boundary (all-cause mortality, cardiovascular mortality, and stroke) and harm boundary (hypoglycemia) were reached.

CONCLUSION

Treatment with basal insulin of patients with type 2 diabetes does not increase the risk of cardiovascular events or death. Despite the increased risk of hypoglycemia, these findings reinforce that insulin is a safe option in the treatment of type 2 diabetes.

Deintensification of basal-bolus insulin after initiation of GLP-1RA in patients with type 2 diabetes under routine care

AIMS

We evaluated de-intensification of basal-bolus insulin (BBI) after initiation of a GLP-1 receptor agonist (GLP-1RA) under routine care.

RESEARCH DESIGN AND METHODS

This retrospective, multicenter study conducted at outpatient clinics in North-East Italy collected data on patients with T2D on BBI who initiated a GLP-1RA. Patients were divided according to whether they de-intensified BBI at the end of observation by stopping prandial insulin.

RESULTS

We included 425 patients with mean age of 61.3 years and 13 years of diabetes duration. Baseline HbA1c was 8.6% and BMI was 35.5 kg/m². After 14 months. 58.6% of patients de-intensified BBI after initiating GLP-1RA: they were younger, had a shorter disease duration, lower HbA1c and insulin dose, and less frequent microangiopathy than those who continued BBI. A probability estimation based on these variables was validated in an independent cohort of 40 patients. Body weight improved in both groups, but HbA1c and fasting plasma glucose significantly declined only among patients who de-intensified BBI. Patients who de-intensified BBI and persisted on GLP-1RA at the last observation (80.7%) had greater HbA1c reductions.

CONCLUSION

Under routine care, GLP-1RA initiation frequently allowed discontinuing BBI, especially among patients with shorter disease duration, lower insulin requirement, and better glucose control.

Effect of background insulin therapy on cardiovascular outcomes with SGLT-2 inhibitors in type 2 diabetes: A meta-analysis of cardiovascular outcome trials

Cardiovascular (CV) benefits of SGLT-2 inhibitors (SGLT-2i) have been consistent in type 2 diabetes mellitus (T2DM). To find whether SGLT-2i show similar CV effects with insulin therapy in T2DM, we conducted a trial-level meta-analysis of CV outcome trials. This meta-analysis found SGLT-2i exert CV benefit, irrespective of background insulin therapy.

The Association Between Baseline Insulin Treatment and Cardiovascular Events: A Meta-Analysis

OBJECTIVE

We conducted a meta-analysis to compare major adverse cardiovascular events (MACEs) in recent diabetes type 2 drugs cardiovascular outcome trials (CVOTs) in the subgroups that used insulin at baseline to the subgroups that did not.

METHODS

English publications from 2010 to 2019 were searched in PubMed and Google Scholar. We searched published clinical trials for CVOTs with new drugs for type 2 diabetes and found 12 publications, of which 8 provided outcomes according to insulin use. We compared the event rate of the primary outcome in the group taking insulin with the one not taking insulin. Data were extracted by 2 investigators independently, including CVOT drug, publication year, sample size, duration of diabetes, mean glycated hemoglobin A1c, mean age, and number of patients in each treatment group. We included 8 trials in the analysis: DECLARE, EMPA-REG, EXSCEL, HARMONY, LEADER, SUSTAIN-6, EXAMINE, and SAVOR-TIMI. The pooled relative risk was 1.52 (95% CI, 1.43 ~ 1.62) when comparing the treatment group with insulin at baseline with the treatment group of patients without insulin use.

RESULTS

In recent CVOTs, patients on insulin regimen along with the new antidiabetic drug had a higher risk ratio of cardiovascular events than patients who used the new antidiabetic drug alone.

Characteristics of diabetes medication-taking in people with mild to moderate intellectual disability compared to those without: a mixed-methods study

AIM

To compare the frequency and factors associated with diabetes medication-taking (depression, perceived side effects, self-efficacy and social support) in people with mild to moderate intellectual disability and those without intellectual disability.

METHODS

In stage 1 of this study, we collated information on diabetes medication-taking and associated factors in 111 people with diabetes: 33 adults with mild to moderate intellectual disability and 78 adults without intellectual disability. Validated instruments measuring medicine-taking, self efficacy, depressive symptoms, perceived level of social support and perceived side effects were administered in both groups. In stage 2, we used an abductive qualitative approach to triangulate stage 1 findings with carers responses (n = 12).

RESULTS

The instruments showed good internal reliability (Cronbach's α = 0.7-0.9). Comparisons between people with intellectual disabilities and those without revealed similar frequency of medication-taking (70% vs 62%; P = 0.41). People with intellectual disabilities and diabetes had significantly higher depressive symptoms, as measured by the Glasgow Depression Scale for people with a Learning Disability (P = 0.04), higher levels of perceived side effects (P = 0.01), and lower confidence levels, as measured by the Perceived Confidence Scale (P = 0.01). The results of stage 2 showed how carers of people with intellectual disabilities and diabetes optimized medication-taking yet infrequently discussed the side effects of medicines.

CONCLUSIONS

Further investigation of medication-taking and side effects may result in the development of an evidence-informed intervention to improve medicines safety in people with intellectual disabilities.

Clinical review of the efficacy and safety of oral semaglutide in patients with type 2 diabetes considered for injectable GLP-1 receptor agonist therapy or currently on insulin therapy

Injectable therapies such as glucagon-like peptide-1 receptor agonists (GLP-1RAs) and insulin are high-efficacy options for people with type 2 diabetes (T2D) who require treatment intensification. In addition to high glycemic efficacy, GLP-1RAs offer weight loss benefits, and some agents have been shown to reduce cardiovascular risk. This article summarizes data from two clinical studies with the first oral GLP-1RA, oral semaglutide, in situations where injectable therapy is often considered, and provides guidance on use in primary care. PIONEER 4 compared oral semaglutide 14 mg with an injectable GLP-1RA, liraglutide 1.8 mg, or placebo in patients uncontrolled on oral glucose-lowering therapies. PIONEER 8 compared oral semaglutide with placebo in patients with T2D already on insulin therapy. Treatment with oral semaglutide gave similar reductions in glycated hemoglobin (HbA_{1 c}) compared with liraglutide at 26 weeks, and significantly greater reductions at 52 weeks. Changes in body weight with oral semaglutide were significantly greater compared with liraglutide after 26 and 52 weeks. Adding oral semaglutide 7 or 14 mg to insulin resulted in significant reductions in HbA_{1 c} and body weight at both 26 and 52 weeks compared with placebo, and facilitated a decrease in total daily insulin dosage. Oral semaglutide was associated with low proportions of patients experiencing severe or blood glucose-confirmed symptomatic hypoglycemia when added to oral glucose-lowering therapies, and did not increase the incidence of such events when added to insulin. The tolerability profile of oral semaglutide was consistent with that seen for injectable GLP-1RAs, with gastrointestinal side effects seen most frequently; most were transient and tended to occur during dose escalation. For patients requiring treatment intensification after oral therapy or as add-on to insulin, oral semaglutide provides effective glucose lowering and body weight loss, with low risk of hypoglycemia, thus broadening the range of therapeutic options for treatment of T2D in primary care.

How do self-care maintenance, self-care monitoring, and self-care management affect glycated haemoglobin in adults with type 2 diabetes? A multicentre observational study

PURPOSE

To evaluate how self-care maintenance, self-care monitoring, and self-care management affect glycated haemoglobin in type 2 diabetes mellitus patients and to set cut-off points of the Self-Care of Diabetes Inventory scales using glycated haemoglobin as outcome of interest.

METHODS

A secondary analysis of a previous multicentre observational cross-sectional study was conducted. Overall, 540 adults with type 2 diabetes mellitus confirmed diagnosis were involved. Socio-demographic and clinical data were collected. Self-care maintenance, self-care monitoring, and self-care management were measured by the Self-Care of Diabetes Inventory. Linear regression models were performed to assess the relationship between self-care maintenance, self-care monitoring, and self-care management and glycated haemoglobin. Receiver operating characteristics curves were carried out to identify the best cut-off score for each self-care scale considering glycated haemoglobin >7% as outcome of interest.

RESULTS

Self-care monitoring and self-care management were associated to glycated haemoglobin in both patients without (self-care monitoring p = 0.0008; self-care management p = 0.0178) and with insulin therapy (self-care monitoring p = 0.0007; self-care management p = 0.0224). Self-care maintenance was associated to glycated haemoglobin in patients without insulin therapy (p = 0.0118). Cut-off scores providing the best performance were 70 points for self-care maintenance and self-care monitoring, and 60 points for self-care management.

CONCLUSIONS

Self-care maintenance, self-care monitoring, and self-care management differently affect glycated haemoglobin in patients with type 2 diabetes mellitus. Clinicians could implement tailored interventions to improve glycaemic control considering the lacking area of self-care.

Efficacy, Safety, and Tolerability of Oral Semaglutide Versus Placebo Added to Insulin With or Without Metformin in Patients With Type 2 Diabetes: The PIONEER 8 Trial

OBJECTIVE

To investigate the efficacy, safety, and tolerability of oral semaglutide added to insulin with or without metformin.

RESEARCH DESIGN AND METHODS

Patients with type 2 diabetes uncontrolled on insulin with or without metformin were randomized to oral semaglutide 3 mg (N = 184), 7 mg (N = 182), or 14 mg (N = 181) or to placebo (N = 184) in a 52-week, double-blind trial. End points were change from baseline to week 26 in HbA_1c (primary) and body weight (confirmatory secondary). Two estimands were defined: treatment policy (effect regardless of trial product discontinuation or rescue medication) and trial product (effect assuming trial product continuation without rescue medication) in randomized patients.

RESULTS

Oral semaglutide was superior to placebo in reducing HbA_1c (estimated treatment difference [ETD] -0.5% [95% CI -0.7, -0.3], -0.9% [-1.1, -0.7], and -1.2% [-1.4, -1.0] for 3, 7, and 14 mg, respectively; P < 0.001) and body weight (ETD -0.9 kg [95% CI -1.8, -0.0], -2.0 kg [-3.0, -1.0], and -3.3 kg [-4.2, -2.3]; P = 0.0392 for 3 mg, P ≤ 0.0001 for 7 and 14 mg) at week 26 (treatment policy estimand). Significantly greater dose-dependent HbA_1c and body weight reductions versus placebo were achieved with oral semaglutide at weeks 26 and 52 (both estimands). The most frequent adverse event with oral semaglutide was nausea (11.4-23.2% of patients vs. 7.1% with placebo; mostly mild to moderate).

CONCLUSIONS

Oral semaglutide was superior to placebo in reducing HbA_1c and body weight when added to insulin with or without metformin in patients with type 2 diabetes. The safety profile was consistent with other glucagon-like peptide 1 receptor agonists.

Open-Label Study to Assess the Efficacy of Ipragliflozin for Reducing Insulin Dose in Patients with Type 2 Diabetes Mellitus Receiving Insulin Therapy

Background and Objective

To avoid insulin-induced hypoglycemia and weight gain, the minimum dose of insulin should be used. In this study, therefore, we examined insulin dose reduction by ipragliflozin add-on therapy in Japanese patients with type 2 diabetes mellitus treated with long-acting basal insulin.

Methods

In this multicenter, open-label study, patients received one ipragliflozin 50-mg tablet once daily in combination with basal insulin for 24 weeks. The primary efficacy endpoint was the change and percent change in insulin dose from baseline to Week 24. Secondary efficacy endpoints included changes in glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), glycoalbumin, cholesterol, leptin, adiponectin, C-peptide, glucagon, body weight, and blood pressure, and number of patients achieving withdrawal of insulin at the end of treatment (EOT). Treatment-emergent adverse events (TEAEs) were evaluated for safety.

Results

In total, 114 patients were screened, 103 were registered, and 97 completed the study. The mean age was 59 years and 72.8% of patients were male. The mean change in insulin dose from baseline at Week 24 was − 6.6 ± 4.4 units/day (p < 0.001); the mean percent change was − 29.87%. HbA1c, FPG, glycoalbumin, glucagon levels, body weight, and blood pressure significantly decreased from baseline to EOT (p < 0.05). Cholesterol, leptin, and adiponectin were unaffected. One patient was able to stop insulin treatment at Week 16. The incidence of TEAEs was 60.2%. Hypoglycemia (10.7%) and pollakiuria (13.6%) were the most common drug-related TEAEs. Conclusions Once-daily 50-mg ipragliflozin enabled a 30% dose reduction of insulin by Week 24 compared with baseline. No major safety concerns were raised.

Clinical Trial Registration

ClinicalTrials.gov (NCT02847091)

Electronic supplementary material

The online version of this article (10.1007/s40261-019-00851-z) contains supplementary material, which is available to authorized users.

Antidiabetic Medications and Mortality Risk in Individuals With Pancreatic Cancer-Related Diabetes and Postpancreatitis Diabetes: A Nationwide Cohort Study

OBJECTIVE

There are no specific treatment guidelines for diabetes of the exocrine pancreas. High-quality studies are warranted to investigate whether the use of antidiabetic medications has survival benefit in individuals with diabetes of the exocrine pancreas. The objective was to determine the risk of mortality associated with the use of antidiabetic medications in individuals with pancreatic cancer-related diabetes (PCRD) and postpancreatitis diabetes mellitus (PPDM).

RESEARCH DESIGN AND METHODS

Nationwide pharmaceutical dispensing data (2006-2015) linked to hospital discharge data were used to identify 1,862 individuals with PCRD or PPDM. Multivariable Cox regression analysis was conducted, and the risk was expressed as hazard ratios and 95% CIs. A 6-month lag was used to minimize reverse causality.

RESULTS

In individuals with PCRD, ever users of metformin (adjusted hazard ratio 0.54; 95% CI 0.46-0.63) and ever users of insulin (adjusted hazard ratio 0.46; 95% CI 0.39-0.55) had significantly lower risks of mortality compared with never users of antidiabetic medications. These associations attenuated toward the null with the use of a 6-month lag. In individuals with PPDM, ever users of metformin had a significantly lower risk of mortality (adjusted hazard ratio 0.51; 95% CI 0.36-0.70), whereas ever-users of insulin did not have a significantly changed risk of mortality (adjusted hazard ratio 0.75; 95% CI 0.49-1.14) compared with never users of antidiabetic medications. The former association remained significant with the use of a 6-month lag.

CONCLUSIONS

Metformin promotes a survival benefit in individuals with PPDM but not PCRD. Reverse causality may play a role in the association between insulin use and mortality in PCRD.

GLUcose COntrol Safety & Efficacy in type 2 DIabetes, a systematic review and NETwork meta-analysis

BACKGROUND

The last international consensus on the management of type 2 diabetes (T2D) recommends SGLT-2 inhibitors or GLP-1 agonists for patients with clinical cardiovascular (CV) disease; metformin remains the first-line glucose lowering medication. Last studies suggested beneficial effects of SGLT-2 inhibitors or GLP-1 agonists compared to DPP-4 inhibitors, in secondary CV prevention. Recently, a potential benefit of SGLT-2 inhibitors in primary CV prevention also has been suggested. However, no comparison of all the new and the old hypoglycemic drugs is available on CV outcomes. We aimed to compare the effects of old and new hypoglycemic drugs in T2D, on major adverse cardiovascular events (MACE) and mortality.

METHODS AND FINDINGS

We conducted a systematic review and network meta-analysis of clinical trials. Randomized trials, blinded or not, assessing contemporary hypoglycemic drugs on mortality or MACE in patients with T2D, were searched for in Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov. References screening and data extraction were done by multiple observers. Each drug was analyzed according to its therapeutic class. A random Bayesian network meta-analysis model was used. The primary outcomes were overall mortality, cardiovascular mortality, and MACE. Severe adverse events and severe hypoglycemia were also recorded. 175,966 patients in 34 trials from 1970 to 2018 were included. No trials evaluating glinides or alpha glucosidase inhibitors were found. 17 trials included a majority of patients with previous cardiovascular history, 16 trials a majority of patients without. Compared to control, SGLT-2 inhibitors were associated with a decreased risk of overall mortality (OR = 0.84 [95% CrI: 0.74; 0.95]), SGLT-2 inhibitors and GLP-1 agonists with a decreased risk of MACE (OR = 0.89 [95% CrI: 0.81; 0.98] and OR = 0.88 [95% CrI: 0.81; 0.95], respectively). Compared to DPP-4 inhibitors, SGLT-2 inhibitors were associated with a decreased risk of overall mortality (OR = 0.82 [95% CrI: 0.69; 0.98]), GLP-1 agonists with a decreased risk of MACE (OR = 0.88 [95% CrI: 0.79; 0.99]). Insulin was also associated with an increased risk of MACE compared to GLP-1 agonists (OR = 1.19 [95% CrI: 1.01; 1.42]). Insulin and sulfonylureas were associated with an increased risk of severe hypoglycemia. In the trials including a majority of patients without previous CV history, the comparisons of SGLT-2 inhibitors, metformin and control did not showed significant differences on primary outcomes. We limited our analysis at the therapeutic class level.

CONCLUSIONS

SGLT-2 inhibitors and GLP-1 agonists have the most beneficial effects, especially in T2D patients with previous CV diseases. Direct comparisons of SGLT-2 inhibitors, GLP-1 agonists and metformin are needed, notably in primary CV prevention.

TRIAL REGISTRATION

PROSPERO CRD42016043823.

Cardiovascular protection in type 2 diabetes: Insights from recent outcome trials

This review examines recent randomized controlled cardiovascular (CV) outcome trials of glucose-lowering therapies in type 2 diabetes and their impact on the treatment of patients with type 2 diabetes. The trials were designed to comply with regulatory requirements to confirm that major adverse cardiac events (MACE) are not detrimentally affected by such therapies. Trials involving dipeptidyl peptidase-4 (DPP-4) inhibitors did not alter a composite MACE outcome comprising CV deaths, non-fatal myocardial infarction and non-fatal stroke; however, the possibility that some members of this class might incur a small increased risk or worsening of heart failure cannot be excluded. Some studies on glucagon-like peptide-1 receptor agonists (liraglutide: LEADER trial; semaglutide: SUSTAIN-6 trial) found significant benefits for MACE, while treatment with sodium-glucose co-transporter-2 inhibitors (empagliflozin: EMPA-REG OUTCOME trial; canagliflozin: CANVAS trial) also significantly reduced MACE and reduced hospitalization for heart failure. Comparisons among trials are complicated by variance in the populations recruited, particularly CV status at randomization, and differences in trial design, data collection and analyses. A large proportion of patients recruited into these trials have previously experienced adverse CV events; thus, the therapies are mostly assessing secondary prevention of a further event. This contrasts with the overall type 2 diabetes population receiving glucose-lowering therapies, of whom the majority will not have had MACE and will be regarded as primary prevention. Overall, the trials provide reassuring evidence that new glucose-lowering medications do not adversely affect CV events and some of these agents may offer CV protection.

Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.

Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication, and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.

The pharmacokinetics and pharmacodynamics of SGLT2 inhibitors for type 2 diabetes mellitus: the latest developments

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a complex metabolic disorder associated with high cardiovascular (CV) risk. Some of the therapeutic strategies are contraindicated in patients with concomitant heart disease. However, the newest antidiabetic medications, sodium-glucose cotransporter 2 (SGLT2) inhibitors, have shown to significantly reduce CV mortality and heart failure (HF) hospitalizations. The mechanism behind these surprising cardiac benefits remains unclear. Areas covered: This article reviews the pharmacokinetic, pharmacodynamics, efficacy, and safety data for the different SGLT2 inhibitors. Specific attention is devoted to the postulated mechanisms of action for their benefit. The therapeutic efficacy and potential use in different indications outside T2DM such as HF, T1DM, and renal disease are also discussed. Expert opinion: SGLT2 inhibitors have an excellent pharmacokinetic and pharmacodynamic profile. Importantly, SGLT2 inhibitors are a safe and efficacious treatment option for T2DM. Given their cardiac benefits (reduction in HF and death) and the low incidence of adverse events, SGLT2 inhibitors are being currently studied as a treatment for HF also in nondiabetic individuals. These agents seem to represent a shift in the treatment of HF patients regardless their glycemic profile.

Renal Outcomes of Antidiabetic Treatment Options for Type 2 Diabetes-A Proposed MARE Definition

One of the most critical long-term complications of type 2 diabetes is nephropathy, currently termed diabetic kidney disease. Although the prevalence is increasing, renal outcomes are heterogeneously defined. Intensive glucose control is effective for the prevention of microvascular complications, including kidney disease. However, the impact of specific drugs on renal outcome measures such as the incidence of kidney disease, albuminuria, progression to end-stage kidney disease, or death of renal cause remains unclear. Comparison of agents or drug classes is impossible, as renal outcomes are inconsistently defined in trials. Recent publications include more stringent criteria, but use only composite endpoints, which can reveal significant results driven by a single surrogate marker but not clinical events of true relevance to patients. This review discusses renal outcomes related to antidiabetic agents for type 2 diabetes, in an attempt to determine the influence of specific drugs on the incidence of diabetic kidney disease and various renal outcomes. There are marked differences among the various agents, but direct comparisons are difficult due to heterogeneous measures. Statements from Kidney Disease Improving Global Outcomes (KDIGO) or European Renal Best Practice (ERBP) highlight that “standardized outcome reporting is key to achieving evidence-based guidance and improving clinical care for patients.” Renal outcome studies including a well-defined, standardized core set of patient-relevant outcomes are needed. Here, we propose to define and establish major adverse renal events (MARE) as the outcome measure for future studies.

Impact of multimorbidity on healthcare professional task shifting potential in patients with type 2 diabetes in primary care: a French cross-sectional study

OBJECTIVES

To estimate the transferability of processes of care from general practitioners (GPs) to allied healthcare professionals and the determinants of such transferability.

DESIGN

French national cross-sectional multicentre study SETTING: 128 family practices providing supervised training for residents in general practice.

PARTICIPANTS

All patients consulting with their GP over a total number of 20 days (ie, 1 day a week from December 2011 to April 2012). Encounters where type 2 diabetes was one of the managed health problems were selected for analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Processes that were associated with specific health problems were collected by 54 residents. Potential process transferability was the main outcome assessed, as well as the professionals involved in the collaboration and the eventual conditions associated with transfer.

RESULTS

From 8572 processes of care that concerned 1088 encounters of patients with diabetes, 21.9% (95% CI 21.1% to 22.8%) were considered eligible for transfer from GPs to allied healthcare professionals (78.1% to nurses, 36.7% to pharmacists). Processes were transferable with condition(s) for 70.6% (ie, a protocol, shared record or supervision). The most transferable processes concerned health maintenance (32.1%) and cardiovascular risk factors (hypertension (28.7%), dyslipidaemia (25.3%) and diabetes (24.3%)). Multivariate analysis showed that educational processes or a long-term condition status were associated with increased transferability (OR 3.26 and 1.47, respectively), whereas patients with higher intellectual occupations or those with two or more associated health problems were associated with lower transferability (OR 0.33 and 0.81, respectively).

CONCLUSIONS

A significant part of GP activity relating to patients with multimorbidity including type 2 diabetes could be transferred to allied healthcare professionals, mainly on prevention and global education to cardiovascular risk factors. The organisational and finance conditions of team work as views of patients and healthcare professionals must be explored before implementation in primary care.

β-Hydroxybutyrate improves β-cell mitochondrial function and survival

Pharmacological interventions aimed at improving outcomes in type 2 diabetes and achieving normoglycaemia, including insulin therapy, are increasingly common, despite the potential for substantial side effects. Carbohydrate-restricted diets that result in increased ketogenesis have effectively been used to improve insulin resistance, a fundamental feature of type 2 diabetes. In addition, limited evidence suggests that states of ketogenesis may also improve β-cell function in type 2 diabetics. Considering how little is known regarding the effects of ketones on β-cell function, we sought to determine the specific effects of β-Hydroxybutyrate (βHB) on pancreatic β-cell physiology and mitochondrial function. βHB treatment increased β-cell survival and proliferation, while also increasing mitochondrial mass, respiration and adenosine triphosphate (ATP) production. Despite these improvements, were unable to detect an increase in β-cell or islet insulin production and secretion. Collectively, these findings have two implications. Firstly, they indicate that β-cells have improved survival and proliferation in the midst of βHB, the circulating form of ketones. Secondly, insulin secretion does not appear to be directly related to apparent improvements in mitochondrial function and cellular proliferation.

Comparative effectiveness and safety of different basal insulins in a real-world setting

AIMS

To compare glucose control and safety of different basal insulin therapies (BI, including Insulin NPH, glargine and detemir) in real-world clinical settings based on a large-scale registry study.

METHODS

In this multi-center 6-month prospective observational study, patients with type 2 diabetes (HbA1c ≥ 7%) who were uncontrolled by oral anti-diabetic drugs (OADs) and were willing to initiate BI therapy were enrolled from 209 hospitals within 8 regions of China. Type and dose of BI were at the physician's discretion and the patients' willingness. Interviews were conducted at 0 months (visit 1), 3 months (visit 2) and 6 months (visit 3). Outcomes included change in HbA1c, hypoglycemia rate and body weight from baseline at 6 months.

RESULTS

A total of 16 341 and 9002 subjects were involved in Intention-To-Treat (ITT) and per-protocol (PP) analysis, respectively. After PS regression adjustment, ITT analysis showed that reduction in HbA1c in glargine (2.2% ± 2.1%) and detemir groups (2.2% ± 2.1%) was higher than that in the NPH group (2.0% ± 2.2%) (P < .01). The detemir group had the lowest weight gain (-0.1 ± 2.9 kg) compared with the glargine (+0.1 ± 3.0 kg) and NPH (+0.3 ± 3.1 kg) groups (P < .05). The glargine group had the lowest rate of minor hypoglycaemia, while there was no difference in severe hypoglycaemia among the 3 groups. The results observed in PP analyses were consistent with those in ITT analysis.

CONCLUSION

In a real-world clinical setting in China, treatment with long-acting insulin analogues was associated with better glycaemic control, as well as less hypoglycaemia and weight gain than treatment with NPH insulin in type 2 diabetes patients. However, the clinical relevance of these observations must be interpreted with caution.

Clinical Effectiveness and Impact on Insulin Therapy Cost After Addition of Dapagliflozin to Patients with Uncontrolled Type 2 Diabetes

INTRODUCTION

Dapagliflozin, a sodium glucose co-transporter 2 (SGLT2) inhibitor, is a promising drug approved for the treatment of type 2 diabetes mellitus (T2DM). However, its cost is an obstacle for use in developing countries like India. Thus, we aimed to analyse the impact on the cost of insulin therapy after adding dapagliflozin for patients using insulin in real-world clinical practice.

METHODS

This retrospective chart review study included patients with uncontrolled T2DM previously on maximum doses of OADs and insulin therapy, initiated on dapagliflozin. Parameters measured were: HbA1c, changes in weight and insulin dosage, frequency and cost, at baseline and after 3 months of adding dapagliflozin 10 mg. Hospital records of patients attending the diabetes outpatient departments at the study centres were scrutinised to identify eligible patients. A treat-to-target approach was used to make changes in the insulin dosages and regimen. The cost of insulin was calculated based on the total daily dose, cost per unit based on the formulation and insulin delivery device. Statistical analysis included descriptive and inferential methods.

RESULTS

Overall, 70 patients meeting the inclusion criteria were included in the study. The mean age of patients and duration of T2DM were 52.6 ± 10 and 12 ± 5 years respectively. The mean reduction in HbA1c and weight was 2.1 ± 1% (p < 0.01) and 2.4 ± 1 kg (p < 0.01) respectively. Genital mycotic infections were reported in two (2.8%) patients. The mean reduction in the total daily dose of insulin was 9.5 ± 6 units. A significant reduction in the daily insulin requirement (19.87%, p < 0.01) was observed. The cost of insulin decreased by 22.3% or 17.8 ± 15 INR per day ($0.27 ± 0.22 per day) and the frequency of insulin shots administered per day decreased significantly (p < 0.01). In 12.8% and 2.8% of patients the frequency of administration of insulin decreased by one and two injections per day respectively.

CONCLUSIONS

Reduction in HbA1c and body weight along with minimal side effects was observed. Addition of dapagliflozin reduced the insulin daily dose requirement and cost of insulin therapy in these patients.

FUNDING

Diacon Hospital, Bangalore, India.