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Attri B, Nagendra L, Dutta D, Shetty S, Shaikh S, Kalra S, Bhattacharya S. Prandial Insulins: A Person-Centered Choice. Curr Diab Rep 2024; 24:131-145. [PMID: 38568467 DOI: 10.1007/s11892-024-01540-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 05/12/2024]
Abstract
PURPOSE OF REVIEW Postprandial hyperglycemia, or elevated blood glucose after meals, is associated with the development and progression of various diabetes-related complications. Prandial insulins are designed to replicate the natural insulin release after meals and are highly effective in managing post-meal glucose spikes. Currently, different types of prandial insulins are available such as human regular insulin, rapid-acting analogs, ultra-rapid-acting analogs, and inhaled insulins. Knowledge about diverse landscape of prandial insulin will optimize glycemic management. RECENT FINDINGS Human regular insulin, identical to insulin produced by the human pancreas, has a slower onset and extended duration, potentially leading to post-meal hyperglycemia and later hypoglycemia. In contrast, rapid-acting analogs, such as lispro, aspart, and glulisine, are new insulin types with amino acid modifications that enhance their subcutaneous absorption, resulting in a faster onset and shorter action duration. Ultra-rapid analogs, like faster aspart and ultra-rapid lispro, offer even shorter onset of action, providing better meal-time flexibility. The Technosphere insulin offers an inhaled route for prandial insulin delivery. The prandial insulins can be incorporated into basal-bolus, basal plus, or prandial-only regimens or delivered through insulin pumps. Human regular insulin, aspart, lispro, and faster aspart are recommended for management of hyperglycemia during pregnancy. Ongoing research is focused on refining prandial insulin replacement and exploring newer delivery methods. The article provides a comprehensive overview of various prandial insulin options and their clinical applications in the management of diabetes.
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Affiliation(s)
- Bhawna Attri
- Department of Endocrinology, Sarvodaya Hospital, Faridabad, Haryana, India
| | - Lakshmi Nagendra
- Department of Endocrinology, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
| | - Deep Dutta
- Department of Endocrinology, Center for Endocrinology Diabetes Arthritis and Rheumatism (CEDAR) Super-Speciality Healthcare, Dwarka, Delhi, India
| | - Sahana Shetty
- Department of Endocrinology, Kasturba Medical College, Manipal, Karnataka, India
| | - Shehla Shaikh
- Department of Endocrinology, Saifee Hospital, Mumbai, Maharashtra, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
| | - Saptarshi Bhattacharya
- Department of Endocrinology, Indraprastha Apollo Hospitals, Sarita Vihar, Mathura Road, Delhi, 110076, India.
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Jalil JE, Gabrielli L, Ocaranza MP, MacNab P, Fernández R, Grassi B, Jofré P, Verdejo H, Acevedo M, Cordova S, Sanhueza L, Greig D. New Mechanisms to Prevent Heart Failure with Preserved Ejection Fraction Using Glucagon-like Peptide-1 Receptor Agonism (GLP-1 RA) in Metabolic Syndrome and in Type 2 Diabetes: A Review. Int J Mol Sci 2024; 25:4407. [PMID: 38673991 PMCID: PMC11049921 DOI: 10.3390/ijms25084407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/02/2024] [Accepted: 04/07/2024] [Indexed: 04/28/2024] Open
Abstract
This review examines the impact of obesity on the pathophysiology of heart failure with preserved ejection fraction (HFpEF) and focuses on novel mechanisms for HFpEF prevention using a glucagon-like peptide-1 receptor agonism (GLP-1 RA). Obesity can lead to HFpEF through various mechanisms, including low-grade systemic inflammation, adipocyte dysfunction, accumulation of visceral adipose tissue, and increased pericardial/epicardial adipose tissue (contributing to an increase in myocardial fat content and interstitial fibrosis). Glucagon-like peptide 1 (GLP-1) is an incretin hormone that is released from the enteroendocrine L-cells in the gut. GLP-1 reduces blood glucose levels by stimulating insulin synthesis, suppressing islet α-cell function, and promoting the proliferation and differentiation of β-cells. GLP-1 regulates gastric emptying and appetite, and GLP-1 RA is currently indicated for treating type 2 diabetes (T2D), obesity, and metabolic syndrome (MS). Recent evidence indicates that GLP-1 RA may play a significant role in preventing HFpEF in patients with obesity, MS, or obese T2D. This effect may be due to activating cardioprotective mechanisms (the endogenous counter-regulatory renin angiotensin system and the AMPK/mTOR pathway) and by inhibiting deleterious remodeling mechanisms (the PKA/RhoA/ROCK pathway, aldosterone levels, and microinflammation). However, there is still a need for further research to validate the impact of these mechanisms on humans.
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Affiliation(s)
- Jorge E. Jalil
- Pontificia Universidad Católica de Chile, School of Medicine, Division of Cardiovascular Diseases, Santiago 8330055, Chile; (L.G.); (P.M.); (R.F.); (H.V.); (M.A.); (S.C.); (L.S.); (D.G.)
| | - Luigi Gabrielli
- Pontificia Universidad Católica de Chile, School of Medicine, Division of Cardiovascular Diseases, Santiago 8330055, Chile; (L.G.); (P.M.); (R.F.); (H.V.); (M.A.); (S.C.); (L.S.); (D.G.)
| | - María Paz Ocaranza
- Pontificia Universidad Católica de Chile, School of Medicine, Division of Cardiovascular Diseases, Santiago 8330055, Chile; (L.G.); (P.M.); (R.F.); (H.V.); (M.A.); (S.C.); (L.S.); (D.G.)
| | - Paul MacNab
- Pontificia Universidad Católica de Chile, School of Medicine, Division of Cardiovascular Diseases, Santiago 8330055, Chile; (L.G.); (P.M.); (R.F.); (H.V.); (M.A.); (S.C.); (L.S.); (D.G.)
| | - Rodrigo Fernández
- Pontificia Universidad Católica de Chile, School of Medicine, Division of Cardiovascular Diseases, Santiago 8330055, Chile; (L.G.); (P.M.); (R.F.); (H.V.); (M.A.); (S.C.); (L.S.); (D.G.)
| | - Bruno Grassi
- Pontificia Universidad Católica de Chile, School of Medicine, Department of Nutrition and Diabetes, Santiago 8330055, Chile; (B.G.); (P.J.)
| | - Paulina Jofré
- Pontificia Universidad Católica de Chile, School of Medicine, Department of Nutrition and Diabetes, Santiago 8330055, Chile; (B.G.); (P.J.)
| | - Hugo Verdejo
- Pontificia Universidad Católica de Chile, School of Medicine, Division of Cardiovascular Diseases, Santiago 8330055, Chile; (L.G.); (P.M.); (R.F.); (H.V.); (M.A.); (S.C.); (L.S.); (D.G.)
| | - Monica Acevedo
- Pontificia Universidad Católica de Chile, School of Medicine, Division of Cardiovascular Diseases, Santiago 8330055, Chile; (L.G.); (P.M.); (R.F.); (H.V.); (M.A.); (S.C.); (L.S.); (D.G.)
| | - Samuel Cordova
- Pontificia Universidad Católica de Chile, School of Medicine, Division of Cardiovascular Diseases, Santiago 8330055, Chile; (L.G.); (P.M.); (R.F.); (H.V.); (M.A.); (S.C.); (L.S.); (D.G.)
| | - Luis Sanhueza
- Pontificia Universidad Católica de Chile, School of Medicine, Division of Cardiovascular Diseases, Santiago 8330055, Chile; (L.G.); (P.M.); (R.F.); (H.V.); (M.A.); (S.C.); (L.S.); (D.G.)
| | - Douglas Greig
- Pontificia Universidad Católica de Chile, School of Medicine, Division of Cardiovascular Diseases, Santiago 8330055, Chile; (L.G.); (P.M.); (R.F.); (H.V.); (M.A.); (S.C.); (L.S.); (D.G.)
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Caruso I, Di Gioia L, Di Molfetta S, Cignarelli A, Palmer SC, Natale P, Strippoli GF, Perrini S, Natalicchio A, Laviola L, Giorgino F. Glucometabolic outcomes of GLP-1 receptor agonist-based therapies in patients with type 2 diabetes: a systematic review and network meta-analysis. EClinicalMedicine 2023; 64:102181. [PMID: 37719418 PMCID: PMC10500557 DOI: 10.1016/j.eclinm.2023.102181] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 09/19/2023] Open
Abstract
Background Innovative GLP-1 receptor agonist (GLP-1RA)-based treatment strategies-such as tirzepatide, GLP-1RA plus basal insulin fixed-ratio combinations [FRC], GLP-1RA plus sodium glucose cotransporter-2 inhibitors [SGLT-2i] combinations, and high-dose GLP-1RA-have been listed among the most efficacious options for type 2 diabetes management. However, differences in their glucometabolic effects have not been assessed in dedicated head-to-head trials. In the absence of such trials, we aimed to provide a useful comparison among these treatment strategies to guide clinical practice. Methods In this network meta-analysis, we searched PubMed, MEDLINE, and Web of Science (from database inception to June 24, 2023) for randomised controlled studies, published in English, that enrolled individuals with type 2 diabetes treated with tirzepatide, iGlarLixi, iDegLira, GLP-1RA plus SGLT-2i combination, or high-dose GLP-1RA (dulaglutide 3 mg and 4.5 mg, semaglutide 2 mg) compared with placebo or active comparators. Eligible studies reported change from baseline in HbA1c as an outcome, which was the primary outcome of this analysis. Secondary outcomes were changes in fasting and post-prandial glucose, bodyweight, LDL-cholesterol, blood pressure and risk of hypoglycaemia. We assessed risk of bias through the Cochrane Collaboration's tool (RoB2 tool), publication bias through visual inspection of funnel plots and Egger's test, and heterogeneity by comparing the magnitude of the common between-study variance (τ2) for each outcome with empirical distributions of heterogeneity variances. This network meta-analysis was registered in PROSPERO (CRD42022329878). Findings 40 trials were included. Tirzepatide 15 mg ranked first in terms of HbA1c reduction compared to other GLP-1RA-based strategies, even those including insulin (vs. iDegLira MD -0.40%, 95% CI [-0.66; -0.14], low certainty; vs. iGlarLixi MD -0.48%, 95% CI [-0.75; -0.21], low certainty), without increasing the risk of hypoglycaemia (vs. iDegLira OR 0.35, 95% CI [0.16; 0.79], high certainty; vs. iGlarLixi OR 0.31, 95% CI [0.20; 0.48], high certainty). Tirzepatide 15 mg was also the most efficacious on weight lowering, even compared to high-dose GLP-1RA (eg, semaglutide 2 mg MD -6.56 kg, 95% CI [-7.38; -5.73], low certainty) and GLP-1RA plus SGLT-2i combination (MD -4.61 kg, 95% CI [-5.29; -3.93], low certainty). Risk of bias and publication bias were generally low throughout studies, while high levels of heterogeneity were detected for most outcomes. Interpretation Aiming to support clinicians in tailoring treatment to patients' needs, we suggest that a hierarchy among treatment strategies be devised considering the best options for type 2 diabetes. Tirzepatide, followed by GLP-1RA plus basal insulin FRC and GLP-1RA plus SGLT-2i combination, was associated with greater benefit on HbA1c than high-dose GLP-1RA. Funding Fondazione per la Ricerca Biomedica "Saverio e Isabella Cianciola" and Next Generation EU, in the context of the National Recovery and Resilience Plan, Investment PE8-Project Age-It: Ageing Well in an Ageing Society.
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Affiliation(s)
- Irene Caruso
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Ludovico Di Gioia
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Sergio Di Molfetta
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Angelo Cignarelli
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | | | - Patrizia Natale
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Nephrology, Dialysis and Transplantation, University of Bari Aldo Moro, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Giovanni F.M. Strippoli
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Nephrology, Dialysis and Transplantation, University of Bari Aldo Moro, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Sebastio Perrini
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Annalisa Natalicchio
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Luigi Laviola
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Francesco Giorgino
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
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Vergès B, Aboyans V, Angoulvant D, Boutouyrie P, Cariou B, Hyafil F, Mohammedi K, Amarenco P. Protection against stroke with glucagon-like peptide-1 receptor agonists: a comprehensive review of potential mechanisms. Cardiovasc Diabetol 2022; 21:242. [PMID: 36380358 PMCID: PMC9667639 DOI: 10.1186/s12933-022-01686-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
Several randomized controlled trials have demonstrated the benefits of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on ischemic stroke in patients with diabetes. In this review, we summarize and discuss the potential mechanisms of stroke protection by GLP-1RAs. GLP-1RAs exert multiple anti-atherosclerotic effects contributing to stroke prevention such as enhanced plaque stability, reduced vascular smooth muscle proliferation, increased nitric oxide, and improved endothelial function. GLP-1RAs also lower the risk of stroke by reducing traditional stroke risk factors including hyperglycemia, hypertension, and dyslipidemia. Independently of these peripheral actions, GLP-1RAs show direct cerebral effects in animal stroke models, such as reduction of infarct volume, apoptosis, oxidative stress, neuroinflammation, excitotoxicity, blood-brain barrier permeability, and increased neurogenesis, neuroplasticity, angiogenesis, and brain perfusion. Despite these encouraging findings, further research is still needed to understand more thoroughly the mechanisms by which GLP-1RAs may mediate stroke protection specifically in the human diabetic brain.
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Affiliation(s)
- Bruno Vergès
- grid.5613.10000 0001 2298 9313Department of Endocrinology, Diabetes and Metabolic Disorders, Dijon University Hospital, INSERM Unit, LNC-UMR 1231, University of Burgundy, Dijon, France
| | - Victor Aboyans
- Department of Cardiology, EpiMaCT - INSERM UMR, Dupuytren University Hospital, Limoges University, 1094 & IRD 270, Limoges, France
| | - Denis Angoulvant
- EA4245 Transplantation, Immunity & Inflammation, Department of Cardiology, University of Tours, Tours University Hospital, Tours, France
| | - Pierre Boutouyrie
- Paris Cardiovascular Research CenterUMR-970Department of Pharmacology, INSERM, Georges-Pompidou European Hospital, Paris City University, Paris, France
| | - Bertrand Cariou
- grid.462318.aUniversity of Nantes, Nantes University Hospital Centre, CNRS, INSERM, L’institut du Thorax, Nantes, France
| | - Fabien Hyafil
- grid.414093.b0000 0001 2183 5849Department of Nuclear Medicine, DMU IMAGINA, Georges-Pompidou European Hospital, APHP, Paris City University, Paris, France
| | - Kamel Mohammedi
- grid.412041.20000 0001 2106 639XDepartment of Endocrinology, Diabetes, and Nutrition, University of Bordeaux, INSERM U1034, Pessac, France
| | - Pierre Amarenco
- Neurology and Stroke Center, SOS-TIA Clinic, Bichat Hospital, University of Paris, Paris, France
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Davis TME, Giczewska A, Lokhnygina Y, Mentz RJ, Sattar N, Holman RR. Effect of race on cardiometabolic responses to once-weekly exenatide: insights from the Exenatide Study of Cardiovascular Event Lowering (EXSCEL). Cardiovasc Diabetol 2022; 21:116. [PMID: 35761271 PMCID: PMC9238154 DOI: 10.1186/s12933-022-01555-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/14/2022] [Indexed: 11/25/2022] Open
Abstract
Background To determine whether there were racial differences in short-term cardiometabolic responses to once-weekly exenatide (EQW) in the Exenatide Study of Cardiovascular Event Lowering (EXSCEL). Methods EXSCEL enrolled 14,752 patients with type 2 diabetes (hemoglobin A1c (HbA1c) 6.5–10.0% [48–86 mmol/mol]) with or without cardiovascular disease who were randomized double-blind to EQW or placebo. Background glucose-lowering/other cardiovascular therapies were unaltered for 6 months post-randomization unless clinically essential, facilitating comparison of EQW-associated effects in 14,665 evaluable participants self-identifying as White (n = 11,113), Asian (n = 1444), Black (n = 870), or Other Race (n = 1,238. Placebo-adjusted 6 month absolute changes in cardiometabolic variables were assessed using generalized linear models. Results Mean 6-month placebo-adjusted HbA1c reductions were similar in the four groups (range 0.54–0.67% [5.9 to 7.3 mmol/mol], P = 0.11 for race×treatment interaction), with no significant difference in Asians (reference) versus other groups after covariate adjustment (all P ≥ 0.10). Six-month placebo-adjusted mean changes in systolic (−1.8 to 0.0 mmHg) and diastolic (0.2 to 1.2 mmHg) blood pressure, serum LDL (− 0.06 to 0.02 mmol/L) and HDL (0.00 to 0.01 mmol/L) cholesterol, and serum triglycerides (−0.1 to 0.0 mmol/L) were similar in the racial groups (P ≥ 0.19 for race×treatment interaction and all P ≥ 0.13 for comparisons of Asians with other races). Resting pulse rate increased more in Asians (4 beats/min) than in other groups (≤ 3 beats/min, P = 0.016 for race×treatment interaction and all P ≤ 0.050 for comparisons of Asians with other races). Conclusions Short-term cardiometabolic responses to EQW were similar in the main racial groups in EXSCEL, apart from a greater pulse rate increase in Asians. Trial registration: https://clinicaltrials.gov NCT01144338. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01555-z.
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Lisco G, De Tullio A, Disoteo O, De Geronimo V, Piazzolla G, De Pergola G, Giagulli VA, Jirillo E, Guastamacchia E, Sabbà C, Triggiani V. Basal insulin intensification with GLP-1RA and dual GIP and GLP-1RA in patients with uncontrolled type 2 diabetes mellitus: A rapid review of randomized controlled trials and meta-analysis. Front Endocrinol (Lausanne) 2022; 13:920541. [PMID: 36157450 PMCID: PMC9494570 DOI: 10.3389/fendo.2022.920541] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
Tirzepatide, a dual agonist of Glucose-Dependent Insulinotropic Polypeptide (GIP) and Glucagon-Like Peptide 1 (GLP-1) receptors, improved glucose control and reduced body weight in different therapeutic approaches. Herein, we overviewed the role of GIP and GLP-1 in the pathophysiology of type 2 diabetes and systematically reviewed the efficacy and safety of injectable incretin-based therapy added to basal insulin in light of the results of the SURPASS-5 trial. We identified eleven randomized clinical trials. GLP-1 receptor agonists (GLP-1RAs) or Tirzepatide added to basal insulin than rigorously titrated basal insulin significantly ameliorates glucose control (Δ HbA1c = -1%, 95% CI -1.25; -0.74, I2 94%; Δ FPG = -14.6 mg/dL, 95% CI -21.6-; -7.6, I2 90%; chance to achieve HbA1c <7% = RR 2.62, 95% CI 2.10; 3.26, I2 89%), reduces body weight (Δ = -3.95 kg, 95% CI -5.1, -2.79, I2 96%) without increasing the risk of hypoglycemia (RR = 1.01, 95% CI 0.86; 1.18, I2 7.7%). Tirzepatide provides an impressive weight loss exceeding that observed with GLP-1RAs. Injectable incretin-based therapy plus basal insulin remains a potent and safe therapeutic approach in uncontrolled type 2 diabetes patients previously treated with basal insulin alone. Tirzepatide is expected to ameliorate the management of "diabesity" in this usually difficult-to-treat cluster of patients.
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Affiliation(s)
- Giuseppe Lisco
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, University of Bari “Aldo Moro”, School of Medicine, Policlinico, Bari, Italy
| | - Anna De Tullio
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, University of Bari “Aldo Moro”, School of Medicine, Policlinico, Bari, Italy
| | - Olga Disoteo
- Diabetology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Giuseppina Piazzolla
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, University of Bari “Aldo Moro”, School of Medicine, Policlinico, Bari, Italy
| | - Giovanni De Pergola
- National Institute of Gastroenterology, Saverio de Bellis, Research Hospital, Bari, Italy
| | - Vito Angelo Giagulli
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, University of Bari “Aldo Moro”, School of Medicine, Policlinico, Bari, Italy
| | - Emilio Jirillo
- Department of Basic Medical Sciences, Neuroscience and Sensory Organs, School of Medicine, University of Bari, Bari, Italy
| | - Edoardo Guastamacchia
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, University of Bari “Aldo Moro”, School of Medicine, Policlinico, Bari, Italy
| | - Carlo Sabbà
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, University of Bari “Aldo Moro”, School of Medicine, Policlinico, Bari, Italy
| | - Vincenzo Triggiani
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, University of Bari “Aldo Moro”, School of Medicine, Policlinico, Bari, Italy
- *Correspondence: Vincenzo Triggiani,
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Rosenberg J, Jacob J, Desai P, Park J, Donovan L, Kim JY. Incretin Hormones: Pathophysiological Risk Factors and Potential Targets for Type 2 Diabetes. J Obes Metab Syndr 2021; 30:233-247. [PMID: 34521773 PMCID: PMC8526293 DOI: 10.7570/jomes21053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/11/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
Type 2 diabetes (T2D) is a multifaceted metabolic disorder associated with distinctive pathophysiological disturbances. One of the pathophysiological risk factors observed in T2D is dysregulation of the incretin hormones, glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1). Both hormones stimulate insulin secretion by acting postprandially on pancreatic β-cell receptors. Oral glucose administration stimulates increased insulin secretion in comparison with isoglycemic intravenous glucose administration, a phenomenon known as the incretin effect. While the evidence for incretin defects in individuals with T2D is growing, the etiology behind this attenuated incretin effect in T2D is not clearly understood. Given their central role in T2D pathophysiology, incretins are promising targets for T2D therapeutics. The present review synthesizes the recent attempts to explain the biological importance of incretin hormones and explore potential pharmacological approaches that target the incretins.
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Affiliation(s)
- Jared Rosenberg
- Department of Exercise Science, David B. Falk College of Sport and Human Dynamics, Syracuse University, Syracuse, NY, USA
| | - Jordan Jacob
- Department of Exercise Science, David B. Falk College of Sport and Human Dynamics, Syracuse University, Syracuse, NY, USA
| | - Priya Desai
- Department of Exercise Science, David B. Falk College of Sport and Human Dynamics, Syracuse University, Syracuse, NY, USA
| | - Jeremy Park
- Department of Exercise Science, David B. Falk College of Sport and Human Dynamics, Syracuse University, Syracuse, NY, USA
| | - Lorin Donovan
- Department of Exercise Science, David B. Falk College of Sport and Human Dynamics, Syracuse University, Syracuse, NY, USA
| | - Joon Young Kim
- Department of Exercise Science, David B. Falk College of Sport and Human Dynamics, Syracuse University, Syracuse, NY, USA
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Fonseca VA, Sood M, Galindo RJ. Rationale for the Use of Combination Injectable Therapy in Patients With Type 2 Diabetes Who Have High A1C (≥9%) and/or Long Duration (>8 Years): Executive Summary. Clin Diabetes 2021; 39:141-145. [PMID: 33986566 PMCID: PMC8061553 DOI: 10.2337/cd20-0121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Over recent decades, an improved understanding of the pathophysiology of type 2 diabetes mellitus (T2DM) and glucose regulation has led to innovative research and new treatment paradigms. The discovery of the gut peptide glucagon-like peptide-1 (GLP-1) and its role in glucose regulation paved the way for the class of GLP-1 receptor agonist compounds, or GLP-1RAs. The long-acting GLP-1RAs (dulaglutide, exenatide extended-release, liraglutide, semaglutide [injectable and oral]) are classified as such based on a minimum 24-hour duration of clinically relevant effects after administration. In phase 3 clinical trial programs of long-acting GLP-1RAs, A1C typically was reduced in the range of 1% to 1.5%, with reductions close to 2% in some studies. GLP-1RAs when used alone (without sulfonylureas or insulin) have a low risk of hypoglycemia because, like endogenous GLP-1, their insulinotropic effects are glucose-dependent. In addition to local actions in the gastrointestinal (GI) tract, GLP-1RAs stimulate receptors in the central nervous system to increase satiety, resulting in weight loss. All long-acting GLP-1RAs have, at minimum, been shown to be safe and not increase cardiovascular (CV) risk and most (liraglutide, semaglutide injectable, dulaglutide, albiglutide) have been shown in CV outcomes trials (CVOTs) to significantly reduce the risk of major cardiac adverse events. The class has good tolerability overall, with generally transient GI adverse events being most common. The weekly injectable agents offer scheduling convenience and may promote treatment adherence. One long-acting GLP-1RA is available as an oral daily tablet, which may be preferable for some patients and providers.
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Khan MS, Fonarow GC, McGuire DK, Hernandez AF, Vaduganathan M, Rosenstock J, Handelsman Y, Verma S, Anker SD, McMurray JJ, Kosiborod MN, Butler J. Glucagon-Like Peptide 1 Receptor Agonists and Heart Failure. Circulation 2020; 142:1205-1218. [PMID: 32955939 DOI: 10.1161/circulationaha.120.045888] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
With worsening epidemiological trends for both the incidence and prevalence of type 2 diabetes mellitus (T2DM) and heart failure (HF) worldwide, it is critical to implement optimal prevention and treatment strategies for patients with these comorbidities, either alone or concomitantly. Several guidelines and consensus statements have recommended glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter type 2 inhibitors as add-ons to lifestyle interventions with or without metformin in those at high atherosclerotic cardiovascular disease risk. However, these recommendations are either silent about HF or fail to differentiate between the prevention of HF in those at risk versus the treatment of individuals with manifest HF. Furthermore, these documents do not differentiate among those with different HF phenotypes. This distinction, even though important, may not be critical for sodium-glucose cotransporter type 2 inhibitors in view of the consistent data for benefit for both atherosclerotic cardiovascular disease– and HF-related outcomes that have emerged from the regulatory-mandated cardiovascular outcome trials for all sodium-glucose cotransporter type 2 inhibitors and the recent DAPA-HF trial (Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction)demonstrating the benefit of dapagliflozin on HF-related outcomes in patients with HF with reduced ejection fraction with or without T2DM. However, the distinction may be crucial for glucagon-like peptide-1 receptor agonists and other antihyperglycemic agents. Indeed, in several of the new statements, glucagon-like peptide-1 receptor agonists are suggested treatment not only for patients with T2DM and atherosclerotic cardiovascular disease, but also in those with manifest HF, despite a lack of evidence for the latter recommendation. Although glucagon-like peptide-1 receptor agonists may be appropriate to use in patients at risk for HF, mechanistic insights and observations from randomized trials suggest no clear benefit on HF-related outcomes and even uncertainty regarding the safety in those with HF with reduced ejection fraction. Conversely, theoretical rationales suggest that these agents may benefit patients with HF with preserved ejection fraction. Considering that millions of patients with T2DM have HF, these concerns have public health implications that necessitate the thoughtful use of these therapies. Achieving this aim will require dedicated trials with these drugs in both patients who have HF with reduced ejection fraction and HF with preserved ejection fraction with T2DM to assess their efficacy, safety, and risk-benefit profile.
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Affiliation(s)
| | - Gregg C. Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Darren K. McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | | | | | | | | | - Subodh Verma
- Department of Surgery, University of Toronto, Canada (S.V.)
| | - Stefan D. Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin (S.D.A.)
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Center, University of Glasgow, United Kingdom (J.J.V.M.)
| | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.N.K.)
- University of Missouri–Kansas City (M.N.K.)
- The George Institute for Global Health, Sydney, Australia (M.N.K.)
- University of New South Wales, Sydney, Australia (M.N.K.)
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson (J.B.)
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11
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Alfayez OM, Almohammed OA, Alkhezi OS, Almutairi AR, Al Yami MS. Indirect comparison of glucagon like peptide-1 receptor agonists regarding cardiovascular safety and mortality in patients with type 2 diabetes mellitus: network meta-analysis. Cardiovasc Diabetol 2020; 19:96. [PMID: 32571416 PMCID: PMC7310317 DOI: 10.1186/s12933-020-01070-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 06/16/2020] [Indexed: 12/25/2022] Open
Abstract
Background The cardiovascular outcome trials (CVOTs) have shown that glucagon like peptide-1 receptor agonists (GLP1RAs) have varying degrees of cardiovascular (CV) safety in patients with type 2 diabetes mellitus (T2DM.) The lack of any head-to-head comparative trials among GLP1RAs urged the need for an indirect comparison of these agents. Therefore, this study was conducted to indirectly compare the CV safety and mortality effects among different GLP1RAs in patients with T2DM using network meta-analysis (NMA). Methods Medline was searched to identify GLP1RA CVOTs to date. The outcomes of interest were CV death, myocardial infarction (IM), stroke, and death from any cause. An NMA with binomial likelihood logit link model was used for the binary outcomes. We conducted both fixed effects and random effects models for each outcome, and selected the best model based on the deviance information and the average posterior residual deviance. This NMA was reported in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA-NMA). Results A total of seven GLP1RA CVOTs were included having 56,004 patients. The NMA results showed that oral semaglutide was statistically better than exenatide (OR 0.47, 95% CI 0.21–0.99), dulaglutide (OR 0.46, 95% CI 0.20–0.97), albiglutide (OR 0.45, 95% CI 0.19–0.97), lixisenatide (OR 0.43, 95% CI 0.19–0.92) in reducing CV death events. No significant differences were detected between most of the treatments regarding reducing death from any cause, MI and stroke events. The ranking results showed that oral semaglutide had the highest probability to be ranked first (> 90%) in reducing CV death and death from any cause. Moreover, once weekly semaglutide had the highest probability to be ranked first in reducing MI and stroke events. Conclusion The GLP1RAs have shown significant benefits in terms of CV safety. The indirect comparison and ranking probability results have shown that one weekly semaglutide and oral semaglutide seems to be the preferred option in patients with T2DM and established or at high risk of CVD. This result can aid health care providers, pharmacy and therapeutics committees in hospitals, and insurance companies when deciding which GLP1RA to start or add to their formulary.
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Affiliation(s)
- Osamah M Alfayez
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim, Saudi Arabia
| | - Omar A Almohammed
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.
| | - Omar S Alkhezi
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim, Saudi Arabia
| | | | - Majed S Al Yami
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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12
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Update on postprandial hyperglycemia: The pathophysiology, prevalence, consequences and implications of treating diabetes. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.rceng.2018.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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13
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Pinés Corrales PJ, Bellido Castañeda V, Ampudia-Blasco FJ. Update on postprandial hyperglycaemia: the pathophysiology, prevalence, consequences and implications of treating diabetes. Rev Clin Esp 2020; 220:57-68. [PMID: 30527933 DOI: 10.1016/j.rce.2018.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/02/2018] [Accepted: 06/19/2018] [Indexed: 12/27/2022]
Abstract
To achieve appropriate glycaemic control, postprandial and baseline hyperglycaemia should be reduced. Various epidemiological studies have suggested an association between fluctuations in postprandial blood glucose and cardiovascular risk. However, studies of interventions performed to date have not shown that selective control of postprandial hyperglycaemia is associated with cardiovascular benefits. Accordingly, an appropriate combination of drugs that control both baseline and postprandial hyperglycaemia (individually based on each patient's characteristics) is the best strategy for achieving good glycaemic control. This review seeks to impart to clinicians the concept of postprandial hyperglycaemia, analysing its causes, how to measure it, its prevalence, its consequences and, ultimately, the available therapeutic strategies for the preferential control of the postprandial hyperglycaemia along with baseline hyperglycaemia.
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Affiliation(s)
- P J Pinés Corrales
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Albacete, Albacete, España
| | - V Bellido Castañeda
- Servicio de Endocrinología y Nutrición, Hospital Universitario Cruces, Bilbao, España
| | - F J Ampudia-Blasco
- Unidad de Referencia de Diabetes, Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valencia, Valencia, España.
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14
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Winkler G, Hajós P, Kiss JT. [Glucagon-like peptide-1 (GLP1) and the gastrointestinal tract. GLP1 receptor agonists: overemphasized gastric, forgotten intestinal ("ileal brake") effect?]. Orv Hetil 2019; 160:1927-1934. [PMID: 31786941 DOI: 10.1556/650.2019.31615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Glucagon-like peptide-1 (GLP1) and their receptor agonists - beside their blood glucose lowering and central effects- affect also the gastrointestinal function in many respects. They slow down the stomach emptying, the motility of the small bowel and colon - this is the explanation for the "ileal brake" terminology -, stimulate the function of exocrine pancreatic acinar cells and increase amylase production. GLP1 receptor agonists belong to the defining tools of the blood glucose lowering therapy in type 2 diabetes. Their long- and short-acting derivatives have different influence on the fasting and the postprandial blood glucose, respectively. By introducing the term non-prandial and prandial type analogues - which seems to be forced in light of the newer data - the potential slowdown in gastric emptying is the center of interest, lately, however, especially in the case of long-acting GLP1 variants, at least such attention should be paid to controlling bowel function. The article reviews the physiological effects of GLP1 on the gastrointestinal tract and draws attention to the potential for the prevention of possible side effects through detailed patient information and dietary advises. Orv Hetil. 2019; 160(49): 1927-1934.
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Affiliation(s)
- Gábor Winkler
- II. Belgyógyászat-Diabetológia, Észak-Közép-budai Centrum, Új Szent János Kórház és Szakrendelő Budapest, Diós árok 1-3., 1125.,Elméleti Egészségtudományi Intézet, Miskolci Egyetem, Egészségügyi Kar Miskolc
| | - Péter Hajós
- II. Belgyógyászat-Diabetológia, Észak-Közép-budai Centrum, Új Szent János Kórház és Szakrendelő Budapest, Diós árok 1-3., 1125
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15
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Alexopoulos AS, Buse JB. Initial injectable therapy in type 2 diabetes: Key considerations when choosing between glucagon-like peptide 1 receptor agonists and insulin. Metabolism 2019; 98:104-111. [PMID: 31255662 PMCID: PMC6690751 DOI: 10.1016/j.metabol.2019.06.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/17/2019] [Accepted: 06/24/2019] [Indexed: 12/24/2022]
Abstract
Managing type 2 diabetes is complex and necessitates careful consideration of patient factors such as engagement in self-care, comorbidities and costs. Since type 2 diabetes is a progressive disease, many patients will require injectable agents, usually insulin. Recent ADA-EASD guidelines recommend glucagon-like peptide 1 receptor agonists (GLP-1 RAs) as first injectable therapy in most cases. The basis for this recommendation is the similar glycemic efficacy of GLP-1 RAs and insulin, but with GLP-1 RAs promoting weight loss instead of weight gain, at lower hypoglycemia risk, and with cardiovascular benefits in patients with pre-existing cardiovascular disease. GLP-1 RAs also reduce burden of glucose self-monitoring. However, tolerability and costs are important considerations, and notably, rates of drug discontinuation are often higher for GLP-1 RAs than basal insulin. To minimize risk of gastrointestinal symptoms patients should be started on lowest doses of GLP-1 RAs and up-titrated slowly. Overall healthcare costs may be lower with GLP-1 RAs compared to insulin. Though patient-level costs may still be prohibitive, GLP-1 RAs can replace 50-80 units of insulin daily and reduce costs associated with glucose self-monitoring. Decisions regarding initiating injectable therapy should be individualized. This review provides a framework to guide decision-making in the real-world setting.
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Affiliation(s)
| | - John B Buse
- University of North Carolina, Chapel Hill, NC, United States
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16
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Umpierrez G, Pantalone KM, Atisso CM, Landó LF, Patel H. Relative contribution of basal and postprandial hyperglycaemia stratified by HbA1c categories before and after treatment intensification with dulaglutide. Diabetes Obes Metab 2019; 21:1365-1372. [PMID: 30756511 DOI: 10.1111/dom.13662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/28/2019] [Accepted: 02/09/2019] [Indexed: 01/22/2023]
Abstract
AIM To assess the effect of dulaglutide on the relative contribution of basal hyperglycaemia (BHG) and postprandial hyperglycaemia (PPHG) to overall hyperglycaemia across HbA1c categories in patients with type 2 diabetes. METHODS Data from five phase 3 studies (N = 673) were pooled to assess the change in relative contributions of BHG and PPHG to overall hyperglycaemia across different HbA1c categories after 6 months of treatment intensification with dulaglutide 1.5 mg as monotherapy or with 1 or 2 oral medication(s) in patients with type 2 diabetes. BHG and PPHG were calculated using the area under the curve (AUC) of 7-point self-monitored plasma glucose concentration profiles. As a secondary objective, relative contribution of BHG and PPHG for dulaglutide versus liraglutide, exenatide BID and insulin glargine was assessed by individual studies at 6 months. RESULTS In pooled data, after 6 months of treatment intensification with dulaglutide 1.5 mg, there was a significant reduction from baseline in overall hyperglycaemia (AUCoverall ) [(mean ± SE) -466.31 ± 18.32 mg*h/dL (P < 0.001)], BHG (AUCbasal ) [(mean ± SE) -371.46 ± 16.36 mg*h/dL (P < 0.001)] and PPHG (AUCpostprandial ) [(mean ± SE) -94.84 ± 7.97 mg*h/dL (P < 0.001)]. At baseline, relative contributions of BHG increased and PPHG decreased with increasing HbA1c levels. This pattern was maintained at 6 months, even as overall glycaemia improved with decreasing HbA1c values. CONCLUSIONS In patients with type 2 diabetes, dulaglutide reduces HbA1c by lowering both basal and postprandial hyperglycaemia across various HbA1c levels.
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17
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Sfairopoulos D, Liatis S, Tigas S, Liberopoulos E. Clinical pharmacology of glucagon-like peptide-1 receptor agonists. Hormones (Athens) 2018; 17:333-350. [PMID: 29949126 DOI: 10.1007/s42000-018-0038-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 05/14/2018] [Indexed: 02/06/2023]
Abstract
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are an important asset in the armamentarium for the treatment of type 2 diabetes mellitus (type 2 DM). Incretin failure is a critical etiopathogenetic feature of type 2 DM, which, if reversed, results in improved glycaemic control. GLP-1 RAs are injectable peptides that resemble the structure and function of endogenous incretin GLP-1, but as they are not deactivated by the dipeptidyl peptidase-4 (DPP-4), their half-life is prolonged compared with native GLP-1. Based on their ability to activate GLP-1 receptor, GLP-1 RAs are classified as short-acting (exenatide twice-daily and lixisenatide once-daily), and long-acting (liraglutide once-daily and the once-weekly formulations of exenatide extended-release, dulaglutide, and albiglutide). Semaglutide, another long-acting, once-weekly GLP-1 RA, was recently approved by the FDA and EMA. Although all of these agents potently reduce haemoglobin A1C (HbA1c), there are unique features and fundamental differences among them related to fasting and postprandial hyperglycaemia reduction, weight loss potency, cardiovascular protection efficacy, and adverse events profile. It is imperative that current evidence be integrated and applied in the context of an individualised patient-centred approach. This should include not only glucose management but also targeting as many as possible of the pathophysiologic mechanisms responsible for type 2 DM development and progression.
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Affiliation(s)
- Dimitrios Sfairopoulos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Stavrou Niarchou Str, 45110, Ioannina, Greece
| | - Stavros Liatis
- First Department of Propaedeutic and Internal Medicine, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 10559, Athens, Greece
| | - Stelios Tigas
- Department of Endocrinology, School of Medicine, University of Ioannina, 45110, Ioannina, Greece
| | - Evangelos Liberopoulos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Stavrou Niarchou Str, 45110, Ioannina, Greece.
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18
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Ghosh S, Unnikrishnan AG, Saboo B, Kesavadev J, Aravind SR, Bajaj S, Rajput R, Seshadri K, Verma N, Gupta A, Makkar BM, Saikia M, Kale S, Damodaran S, Dengra A, Eashwar TKM, Maheshwari A, Pendsey S, Phatak SR, Sharma SK, Singh SK, Ramachandran A, Zargar AH, Joshi SR, Sadikot SM. Evidence-based recommendations for insulin intensification strategies after basal insulin in type 2 diabetes. Diabetes Metab Syndr 2017; 11 Suppl 1:S507-S521. [PMID: 28433618 DOI: 10.1016/j.dsx.2017.03.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Indexed: 01/27/2023]
Abstract
Over the time due to progressive nature of diabetes, proactive intensification of the existing insulin therapy becomes imminent as it minimizes patients' exposure to chronic hypo/hyperglycaemia and reduces weight gain while achieving individualized glycaemic targets. This review focuses on the strength of evidence behind various options for intensification, primarily the insulins as also the GLP-1 analogues. The recommendations presented here are meant to serve as a guide for the physician managing type 2 diabetes patients requiring insulin intensification upon failing of basal insulin therapy.
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Affiliation(s)
- Sujoy Ghosh
- Department of Endocrinology and Metabolism, Institute of Post-Graduate Medical Education and Research, Kolkata, India.
| | | | | | | | | | - Sarita Bajaj
- Department of Medicine, Motilal Nehru Medical College, Allahabad, India
| | - Rajesh Rajput
- Department of Endocrinology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
| | - Krishna Seshadri
- Department of Endocrinology and Metabolism, Shri Rama Chandra University, Chennai, India
| | | | | | | | | | | | | | - Ashish Dengra
- Mahi Diabetes & Thyroid Care and Research Center, Jabalpur, India
| | | | - Anuj Maheshwari
- Department of Medicine, Babu Banarasi Das University, Lucknow, India
| | | | | | | | - Surya Kumar Singh
- Department of Endocrinology and Metabolism, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | | | - Abdul H Zargar
- Advanced Center for Diabetes and Endocrine Care, Srinagar, India
| | - Shashank R Joshi
- Lilavati and Bhatia Hospital and Grant Medical College, Mumbai, India
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19
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Abstract
Glycemic fluctuations, characterized by short-term oscillations in plasma glucose, are important when managing type 2 diabetes (T2D) and may be considered a target of glucose-lowering therapies. Continuous glucose monitoring (CGM) has been used to evaluate the effects of different treatments on glycemic fluctuations. This review examines approaches to and the importance of minimizing glycemic fluctuations among patients with T2D. Measures of HbA1c, fructosamine, and glycated albumin reflect a long-term average of plasma glucose, and are therefore unable to provide an accurate measure of short-term glycemic oscillations. CGM provides accurate monitoring of real-time glucose fluctuations and has been used to investigate the effects of lifestyle and treatment on daily glycemic control. Dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter 2 inhibitors, and glucagon-like peptide-1 receptor agonists have demonstrated significant improvements in measures such as the mean amplitude of glucose excursions and standard deviation of CGM. Case studies of two patients with T2D utilizing CGM are also included in this review, which demonstrated that CGM was a useful tool for diagnosing unrecognized hypoglycemia and hyperglycemia in situations in which it was impractical to check fingerstick concentrations. Altogether, the evidence suggests that glycemic fluctuations are a potential target to consider when managing T2D. CGM allows for the real-time evaluation of glycemic fluctuations and may assist in the development of an individualized treatment plan to adequately control short-term oscillations in blood glucose levels.
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Affiliation(s)
- Paresh Dandona
- Department of Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo , Buffalo, New York, USA
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