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Fickweiler W, Mitzner M, Jacoba CMP, Sun JK. Circulatory Biomarkers and Diabetic Retinopathy in Racial and Ethnic Populations. Semin Ophthalmol 2023:1-11. [PMID: 36710371 DOI: 10.1080/08820538.2023.2168488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Clinical staging systems for diagnosis and treatment of diabetic retinopathy (DR) must closely relate to endpoints that are both relevant for patients and feasible for physicians to implement. Current DR staging systems for clinical eye care and research provide detailed phenotypic characterization to predict patient outcomes in diabetes but have limitations. Biochemical biomarkers provide a rich pool of potential candidates for new DR staging systems that can be readily measured in accessible fluids. Circulating biomarkers that are specific to the retina and relate to angiogenesis and inflammation have been suggested as relevant for DR. Although there is a lack of multi-ethnic studies evaluating circulatory biomarkers in DR, variability in circulatory biomarkers have been reported in people from different ethnic and racial backgrounds. Therefore, there is a need for future studies to evaluate individual or combinations of biomarkers in diverse populations with DR from different ethnic and racial backgrounds.
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Affiliation(s)
- Ward Fickweiler
- Research Division, Joslin Diabetes Center, Boston, MA, USA.,Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Margalit Mitzner
- Research Division, Joslin Diabetes Center, Boston, MA, USA.,Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
| | - Cris Martin P Jacoba
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Jennifer K Sun
- Research Division, Joslin Diabetes Center, Boston, MA, USA.,Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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2
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McGill JB, Haller H, Roy-Chaudhury P, Cherrington A, Wada T, Wanner C, Ji L, Rossing P. Making an impact on kidney disease in people with type 2 diabetes: the importance of screening for albuminuria. BMJ Open Diabetes Res Care 2022; 10:e002806. [PMID: 35790319 PMCID: PMC9258490 DOI: 10.1136/bmjdrc-2022-002806] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/09/2022] [Indexed: 12/12/2022] Open
Abstract
Albuminuria is useful for early screening and diagnosis of kidney impairment, especially in people with pre-diabetes or type 2 diabetes (T2D), which is the leading cause of chronic kidney disease (CKD) and end-stage kidney disease (ESKD), associated with increased mortality, poor cardiovascular outcomes, and high economic burden. Identifying patients with CKD who are most likely to progress to ESKD permits timely implementation of appropriate interventions. The early stages of CKD are asymptomatic, which means identification of CKD relies on routine assessment of kidney damage and function. Both albuminuria and estimated glomerular filtration rate are measures of kidney function. This review discusses albuminuria as a marker of kidney damage and cardiorenal risk, highlights the importance of early screening and routine testing for albuminuria in people with T2D, and provides new insights on the optimum management of CKD in T2D using albuminuria as a target in a proposed algorithm. Elevated urine albumin can be used to detect CKD in people with T2D and monitor its progression; however, obstacles preventing early detection exist, including lack of awareness of CKD in the general population, poor adherence to clinical guidelines, and country-level variations in screening and treatment incentives. With albuminuria being used as an entry criterion and a surrogate endpoint for kidney failure in clinical trials, and with novel treatment interventions available to prevent CKD progression, there is an urgent need for early screening and diagnosis of kidney function decline in people with T2D or pre-diabetes.
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Affiliation(s)
- Janet B McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Hermann Haller
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Prabir Roy-Chaudhury
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
- Department of Medicine, WG Hefner VA Medical Center, Salisbury, North Carolina, USA
| | - Andrea Cherrington
- Division of Preventive Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Christoph Wanner
- Division of Nephrology and Hypertension, University Hospital of Würzburg, Würzburg, Germany
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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3
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Biomarkers in systemic sclerosis: mechanistic insights into pathogenesis and treatment. Curr Opin Rheumatol 2021; 33:480-485. [PMID: 34420004 DOI: 10.1097/bor.0000000000000827] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW Systemic sclerosis (SSc) is heterogenous on molecular, cellular, tissue, and clinical levels. Although many biomarkers have been described in clinical studies, few have been rigorously mapped to specific molecular pathways, tissue pathologies, and clinical manifestations. A focused assessment of peripheral blood levels of C-C Motif Chemokine Ligand-18 (CCL18) and periostin illustrates how biomarkers can link molecular mediators to clinical outcomes. RECENT FINDINGS CCL18 is produced by pulmonary macrophages in response to type 2 cytokines and IL6. Elevated serum CCL18 is associated with interstitial lung disease (ILD) in SSc patients and is prognostic for ILD progression. It is pharmacologically modulated by IL6 inhibition, and associated with stabilization of lung function decline but not with improvements in skin fibrosis. Periostin is produced by dermal fibroblasts in SSc in response to type 2 cytokines and transforming growth factor-beta. Elevated serum periostin is associated with cutaneous disease in SSc patients but not ILD. Other cell- and tissue-specific biomarkers detectable in peripheral blood and informative with respect to SSc pathogenesis include KL-6 and SP-D in lung epithelium, osteopontin in lung macrophages, and cartilage oligomeric matrix protein in dermal fibroblasts. SUMMARY Blood biomarkers related to specific molecular mediators, cell types, and tissues of origin can help to link therapeutic targets to treatable traits in SSc.
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Whitehead L, Glass C, Coppell K. The effectiveness of goal setting on glycaemic control for people with type 2 diabetes and prediabetes: A systematic review and meta-analysis. J Adv Nurs 2021; 78:1212-1227. [PMID: 34716594 DOI: 10.1111/jan.15084] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 08/24/2021] [Accepted: 10/16/2021] [Indexed: 11/29/2022]
Abstract
AIM This review assessed the effectiveness of interventions using a goal-setting approach on glycaemic control for people diagnosed with prediabetes or type 2 diabetes. DESIGN A systematic review guided by the Joanna Briggs Institute methodology for conducting systematic reviews of primary research studies was conducted. DATA SOURCES Randomized controlled trials and experimental studies with a minimum follow-up period of 6 months were considered for inclusion. The primary outcome was change in glycaemic control as measured by glycated haemoglobin (%) and/or fasting plasma glucose (mg/dl). A systematic search of seven electronic databases was completed in October 2020. REVIEW METHODS Papers meeting the inclusion criteria were critically appraised using the Joanna Briggs Institute tools for critical appraisal followed by data extraction. A Grading of Recommendations Assessment, Development and Evaluation assessment was conducted to assess the overall certainty of the evidence. Fixed-effect meta-analyses were completed to demonstrate the mean effect for each outcome of interest. RESULTS Twenty one studies were included in this review. Goal setting was more effective than usual care for glycaemic control in prediabetes at 6 months and at 12 months for fasting plasma glucose (mg/dl) and glycated haemoglobin (%). Goal setting was more effective than usual care for glycaemic control in type 2 diabetes for fasting plasma glucose (mg/dl) at 6 months, fasting plasma glucose (mg/dl) at 12 months, glycated haemoglobin (%) at 6 months and glycated haemoglobin (%) at 12 months. CONCLUSION The evidence suggests goal setting is effective in supporting people to achieve glycaemic targets in prediabetes and type 2 diabetes.
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Affiliation(s)
- Lisa Whitehead
- Edith Cowan University, Joondalup, Western Australia, Australia
| | - Courtney Glass
- Edith Cowan University, Joondalup, Western Australia, Australia
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Geybels M, Wolthers BO, Kreiner FF, Rasmussen S, Bauer R. Surrogate endpoint evaluation using data from one large global randomized controlled trial. BMC Med Inform Decis Mak 2021; 21:164. [PMID: 34016120 PMCID: PMC8139150 DOI: 10.1186/s12911-021-01516-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Robust identification of surrogate endpoints can help accelerate the development of pharmacotherapies for diseases traditionally evaluated using true endpoints associated with prolonged follow-up. The meta-analysis-based surrogate endpoint evaluation (SEE) integrates data from multiple, usually smaller, trials to statistically confirm a surrogate endpoint as a robust proxy for the true endpoint. To test the applicability of SEE when only a single, larger trial is available, we analysed the cardiovascular (CV) survival endpoint from the large multinational trial LEADER (9340 subjects) that confirmed the CV safety of a diabetes drug (liraglutide). We evaluated if using country as a trial unit adequately facilitated the meta-analysis and calculation of R2 by country group. METHODS Data were grouped by country, ensuring at least 30 CV deaths (497 in total) in each of the nine resulting by-country groups. In a two-step SEE on the grouped dataset, we first fitted the group-specific Cox proportional hazard models; next, on the trial-level, we regressed the estimated hazard ratio (HR; liraglutide vs placebo) of the true endpoints (CV death: 497 events, or all-cause death: 828 events) on the HR of the surrogate endpoint (major CV adverse event [MACE]: 1302 events) and derived the group-specific R2 and its 95% confidence interval (CI). RESULTS Group-level surrogacy of MACE was supported for CV death but not for all-cause death, with [Formula: see text] values of 0.85 [0.63;1.00]95% CI and 0.23 [0.00;0.67]95% CI, respectively. Sensitivity analyses using different grouping approaches (e.g. grouping by region) corroborated the robustness of the conclusions as well as the appropriateness of the data-grouping approaches. CONCLUSIONS We derived a specific grouping approach to successfully apply SEE on data from a single trial. This may allow for the statistically robust identification and validation of surrogate endpoints based on the abundance of large monolithic outcome trials conducted as part of drug development programmes in, for example, diabetes.
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Affiliation(s)
- Milan Geybels
- Novo Nordisk A/S, Vandtårnsvej 110-114, 2860, Søborg, Denmark
| | | | | | - Søren Rasmussen
- Novo Nordisk A/S, Vandtårnsvej 110-114, 2860, Søborg, Denmark
| | - Robert Bauer
- Novo Nordisk A/S, Vandtårnsvej 110-114, 2860, Søborg, Denmark
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Dankers M, Nelissen-Vrancken MHJMG, Hart BH, Lambooij AC, van Dijk L, Mantel-Teeuwisse AK. Alignment between outcomes and minimal clinically important differences in the Dutch type 2 diabetes mellitus guideline and healthcare professionals' preferences. Pharmacol Res Perspect 2021; 9:e00750. [PMID: 33934550 PMCID: PMC8244004 DOI: 10.1002/prp2.750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 11/10/2022] Open
Abstract
To evaluate the clinical benefit of new medicines for type 2 diabetes mellitus (T2DM), the Dutch guideline committee T2DM in primary care established the importance of outcomes and minimal clinically important differences (MCIDs). The present study used an online questionnaire to investigate healthcare professionals' opinions about the importance of outcomes and preferences for MCIDs. A total of 211 physicians, pharmacists, practice nurses, diabetes nurses, nurse practitioners and physician assistants evaluated the importance of mortality, macro- and microvascular morbidity, HbA1c, body weight, quality of life, (overall) hospital admissions and severe and other hypoglycemia on a 9-point scale. All outcomes were considered critical (mean scores 7-9), except for body weight and other hypoglycemia (mean scores 4-6). Only HbA1c and hospital admissions were valued differently by the guideline committee (not critical). Other relevant outcomes according to the respondents were adverse events, ease of use and costs. Median MCIDs were 4 mmol/mol for HbA1c (guideline: 5 mmol/mol) and 3 kg for body weight (guideline: 5 kg weight gain and 2,5 kg weight loss). Healthcare professionals preferred relative risk reductions of 20% for mortality (guideline: 10%) and macrovascular morbidity (guideline: 25%) and 50% for other hypoglycaemia (guideline: 25%). The MCID of 25% for microvascular morbidity, hospital admissions and severe hypoglycaemia corresponded to the guideline-MCID. Healthcare professionals' preferences were thus comparable to the views of the guideline committee. However, healthcare professionals had a stricter view on the importance of HbA1c and hospital admissions and the MCIDs for mortality and other hypoglycemia.
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Affiliation(s)
- Marloes Dankers
- Dutch Institute for Rational Use of Medicine, Utrecht, the Netherlands.,Department of PharmacoTherapy, -Epidemiology and -Economics (PTEE, Groningen Research Institute of Pharmacy, Faculty of Science and Engineering, University of Groningen, Groningen, the Netherlands
| | | | - Bertien H Hart
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Leidsche Rijn Julius Healthcare Centers, Utrecht, the Netherlands
| | - Anke C Lambooij
- Dutch Institute for Rational Use of Medicine, Utrecht, the Netherlands
| | - Liset van Dijk
- Department of PharmacoTherapy, -Epidemiology and -Economics (PTEE, Groningen Research Institute of Pharmacy, Faculty of Science and Engineering, University of Groningen, Groningen, the Netherlands.,Nivel, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS, Utrecht University, Utrecht, the Netherlands
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Li J, He K, Ge J, Li C, Jing Z. Efficacy and safety of the glucagon-like peptide-1 receptor agonist oral semaglutide in patients with type 2 diabetes mellitus: A systematic review and meta-analysis. Diabetes Res Clin Pract 2021; 172:108656. [PMID: 33434602 DOI: 10.1016/j.diabres.2021.108656] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/25/2020] [Accepted: 01/06/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To evaluate the efficacy and safety of the glucagon-like peptide-1 (GLP-1) receptor agonist (RA) oral semaglutide in the treatment of type 2 diabetes mellitus (T2DM) patients. METHODS Randomized controlled trials comparing oral semaglutide with placebo or other antihyperglycemic agents in T2DM patients were identified by searching PubMed, Embase, Cochrane Library and ClinicalTrials.gov. Risk ratios and mean differences with 95% confidence intervals were used to synthesize the results. RESULTS Ten relevant studies involving 8,536 patients were finally included. Compared with placebo, oral semaglutide significantly reduced hemoglobin A1c (HbA1c), body weight, fasting plasma glucose, self-measured plasma glucose (SMPG), serious adverse events and all-cause death and significantly increased the number of participants who achieved HbA1c < 7.0%. Compared with active comparators, oral semaglutide significantly reduced the level of HbA1c, body weight, and SMPG and significantly increased the number of participants who achieved HbA1c < 7.0%. Compared with placebo or active comparators, oral semaglutide did not increase the incidence of adverse events, hypoglycemia (severe or blood glucose-confirmed symptomatic), myocardial infarction, heart failure requiring hospitalization, stroke or acute pancreatitis but did increase the incidence of nausea, diarrhea and vomiting. CONCLUSIONS Oral semaglutide has favorable efficacy and safety in the treatment of T2DM patients. Oral semaglutide may be superior to liraglutide, dulaglutide, empagliflozin and sitagliptin for T2DM patients who have obesity or poor adherence to injectable GLP-1 RAs.
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Affiliation(s)
- Jingxin Li
- Department of Chinese Pharmacy, Hebei Maternity Hospital, 27 Shifeng Road, Qiaoxi District, Shijiazhuang 050051, Hebei Province, China
| | - Ke He
- Department of Pharmacy, The Fourth Hospital of Shijiazhuang/Shijiazhuang Obstetrics and Gynecology Hospital, 206 Zhongshan East Road, Changan District, Shijiazhuang 050017, Hebei Province, China.
| | - Jun Ge
- Department of Pharmacy, The Fourth Hospital of Shijiazhuang/Shijiazhuang Obstetrics and Gynecology Hospital, 206 Zhongshan East Road, Changan District, Shijiazhuang 050017, Hebei Province, China
| | - Caixia Li
- Department of Pharmacy, The Fourth Hospital of Shijiazhuang/Shijiazhuang Obstetrics and Gynecology Hospital, 206 Zhongshan East Road, Changan District, Shijiazhuang 050017, Hebei Province, China
| | - Zeng Jing
- Department of Pharmacy, The Fourth Hospital of Shijiazhuang/Shijiazhuang Obstetrics and Gynecology Hospital, 206 Zhongshan East Road, Changan District, Shijiazhuang 050017, Hebei Province, China
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Pedrazzi V, Figueiredo FATD, Adami LE, Furlaneto F, Palioto DB, Messora MR. Surrogate endpoints: when to use and when not to use? A critical appraisal of current evidences. Braz Oral Res 2020; 34 Suppl 2:e074. [PMID: 32785485 DOI: 10.1590/1807-3107bor-2020.vol34.0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 09/22/2019] [Indexed: 11/21/2022] Open
Abstract
Clinical research needs to formulate a question, which must be answered by obeying ethical precepts with well-defined inclusion/exclusion criteria and approval of the study on platforms of ethical appreciation and clinical trial records. In comparing the results or clinically relevant outcomes should be prioritized in the study of techniques, products, inputs, drugs and therapies. However, it is not always possible to use long study drawings, with many participants, and with many costs, then look for study designs with surrogate outcomes, usually a shorter path, with less sample size and considerably lower costs to the research, with shorter intervention time. Considering these outcomes as major challenges in clinical research, the premise of this work was to examine in relevant research platforms, studies on the feasibility of using surrogate endpoints for clinically relevant parameters in dentistry, with a critical evaluation of the advantages, disadvantages, and need for validation of substitute parameters for clinical studies. After a critical analysis of the results, it could be concluded that surrogate endpoints may have an important role in the initial process of developing new drugs, faster, with less sampling, and lower risk of side effects for the patient. Careful use of the surrogate endpoints is advised because, even if validated, they can provide ambiguous evidence and not be extrapolated to other populations, and may lead to bias due to the individual interpretation of each researcher. The use of unplanned surrogate outcomes that arise during the study requires a lot of caution.
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Affiliation(s)
- Vinicius Pedrazzi
- Department of Dental Materials and Prosthesis, School of Dentistry of Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | | | - Larisse Eduardo Adami
- Department of Dental Materials and Prosthesis, School of Dentistry of Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Flávia Furlaneto
- Department of Oral & Maxillofacial Surgery and Periodontology, School of Dentistry of Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Daniela Bazan Palioto
- Department of Oral & Maxillofacial Surgery and Periodontology, School of Dentistry of Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Michel Reis Messora
- Department of Oral & Maxillofacial Surgery and Periodontology, School of Dentistry of Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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Prudencio J, Kim M. Diabetes-Related Patient Outcomes through Comprehensive Medication Management Delivered by Clinical Pharmacists in a Rural Family Medicine Clinic. PHARMACY 2020; 8:E115. [PMID: 32660091 PMCID: PMC7558112 DOI: 10.3390/pharmacy8030115] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/03/2020] [Accepted: 07/08/2020] [Indexed: 12/25/2022] Open
Abstract
Two clinical pharmacy faculty members from a college of pharmacy provide comprehensive medication management in a rural family medicine clinic. The data was assessed for patients with diabetes managed by the pharmacists from 1 January 2017 through to 31 December 2019 to determine the service's impact on patient outcomes. The primary outcome of this study is the change in the goal attainment rates of the three clinical goals of hemoglobin A1c, blood pressure, and appropriate statin therapy after pharmacist intervention. A total of 207 patients were included. At baseline, the patients had an average of 1.13 of the three goals met, improving to an average of 2.02 goals met after pharmacist intervention (p < 0.001). At baseline, 4.8% of the patients had met all three clinical goals, improving to 30.9% after pharmacist intervention (p < 0.001). There were significant improvements for the individual goal attainment rates of hemoglobin A1c (24.15% vs. 51.21%, p < 0.001), blood pressure (42.51% vs. 85.51%, p < 0.001), and appropriate statin therapy (45.89% vs. 65.70%, p < 0.001). This data adds to the evidence supporting the integration of clinical pharmacists into primary care clinics to improve patient outcomes related to diabetes.
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Affiliation(s)
- Jarred Prudencio
- Department of Pharmacy Practice, The Daniel K. Inouye College of Pharmacy, University of Hawaii at Hilo, Hilo, HI 96720, USA;
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Visser SA, Bueters TJ. Assessment of translational risk in drug research: Role of biomarker classification and mechanism-based PKPD concepts. Eur J Pharm Sci 2017; 109S:S72-S77. [DOI: 10.1016/j.ejps.2017.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 08/12/2017] [Indexed: 01/10/2023]
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Schott G, Martinez YV, Ediriweera de Silva RE, Renom-Guiteras A, Vögele A, Reeves D, Kunnamo I, Marttila-Vaara M, Sönnichsen A. Effectiveness and safety of dipeptidyl peptidase 4 inhibitors in the management of type 2 diabetes in older adults: a systematic review and development of recommendations to reduce inappropriate prescribing. BMC Geriatr 2017; 17:226. [PMID: 29047372 PMCID: PMC5647559 DOI: 10.1186/s12877-017-0571-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Preventable drug-related hospital admissions can be associated with drugs used in diabetes and the benefits of strict diabetes control may not outweigh the risks, especially in older populations. The aim of this study was to look for evidence on risks and benefits of DPP-4 inhibitors in older adults and to use this evidence to develop recommendations for the electronic decision support tool of the PRIMA-eDS project. Methods Systematic review using a staged approach which searches for systematic reviews and meta-analyses first, then individual studies only if prior searches were inconclusive. The target population were older people (≥65 years old) with type 2 diabetes. We included studies reporting on the efficacy and/or safety of DPP-4 inhibitors for the management of type 2 diabetes. Studies were included irrespective of DPP-4 inhibitors prescribed as monotherapy or in combination with any other drug for the treatment of type 2 diabetes. The target intervention was DPP-4 inhibitors compared to placebo, no treatment, other drugs to treat type 2 diabetes or a non-pharmacological intervention. Results Thirty studies (reported in 33 publications) were included: 1 meta-analysis, 17 intervention studies and 12 observational studies. Sixteen studies were focused on older adults and 14 studies reported subgroup analyses in participants ≥65, ≥70, or ≥75 years. Comorbidities were reported by 26 studies and frailty or functional status by one study. There were conflicting findings regarding the effectiveness of DPP-4 inhibitors in older adults. In general, DPP-4 inhibitors showed similar or better safety than placebo and other antidiabetic drugs. However, these safety data are mainly based on short-term outcomes like hypoglycaemia in studies with HbA1c control levels recommended for younger people. One recommendation was developed advising clinicians to reconsider the use of DPP-4 inhibitors for the management of type 2 diabetes in older adults with HbA1c <8.5% because of scarce data on clinically relevant benefits of their use. Twenty-two of the included studies were funded by pharmaceutical companies and authored or co-authored by employees of the sponsor. Conclusions Other than the surrogate endpoint of improved glycaemic control, data on clinically relevant benefits of DPP-4 inhibitors in the treatment of type 2 diabetes mellitus in older adults is scarce. DPP-4 inhibitors might have a lower risk of hypoglycaemia compared to other antidiabetic drugs but data show conflicting findings for long-term benefits. Further studies are needed that evaluate the risks and benefits of DPP-4 inhibitors for the management of type 2 diabetes mellitus in older adults, using clinically relevant outcomes and including representative samples of older adults with information on their frailty status and comorbidities. Studies are also needed that are independent of pharmaceutical company involvement. Electronic supplementary material The online version of this article (doi:10.1186/s12877-017-0571-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gisela Schott
- Drug Commission of the German Medical Association, Berlin, Germany.
| | - Yolanda V Martinez
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, England
| | - R Erandie Ediriweera de Silva
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, England.,Family Medicine Unit, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Anna Renom-Guiteras
- Institute of General Practice and Family Medicine, Witten/Herdecke University, Witten, Germany.,Department of Geriatrics, University Hospital Parc de Salut Mar, Barcelona, Spain
| | - Anna Vögele
- South Tyrolean Academy of General Practice, Bolzano, Italy
| | - David Reeves
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, England
| | - Ilkka Kunnamo
- Duodecim Medical Publications Ltd, Helsinki, Finland
| | | | - Andreas Sönnichsen
- Institute of General Practice and Family Medicine, Witten/Herdecke University, Witten, Germany
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12
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Schrijnders D, Wever R, Kleefstra N, Houweling ST, van Hateren KJJ, de Bock GH, Bilo HJG, Groenier KH, Landman GWD. Addition of sulphonylurea to metformin does not relevantly change body weight: a prospective observational cohort study (ZODIAC-39). Diabetes Obes Metab 2016; 18:973-9. [PMID: 27265756 PMCID: PMC5129585 DOI: 10.1111/dom.12700] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 05/12/2016] [Accepted: 06/01/2016] [Indexed: 12/18/2022]
Abstract
AIM To investigate changes in body weight trajectories after the addition of individual sulphonylureas (SUs) to metformin in patients with type 2 diabetes. MATERIALS AND METHODS We conducted a retrospective observational cohort study, in a primary care setting in the Netherlands. Patients aged ≥18 years with type 2 diabetes who were included in the ZODIAC cohort between 1998 and 2012 and who received metformin monotherapy at inclusion (n = 29 195), and had used metformin as monotherapy for at least 1 year before receiving dual therapy through the addition of an SU for at least 1 year were eligible for inclusion. The primary outcome was within-drug yearly change in body weight after receiving add-on therapy with individual SUs during 5 years of follow-up. The secondary outcome was within-drug yearly change in glycated haemoglobin (HbA1c). Annual changes in weight and HbA1c were estimated with linear mixed models, adjusted for age, gender and diabetes duration. RESULTS A total of 2958 patients were included. No significant weight changes were observed within and between any of the individual SUs after treatment intensification (p = 0.24). In addition, no significant difference in weight between the add-on therapy combinations was observed (p = 0.26). The average HbA1c the year before intensification was 7.2% (55 mmol/mol) and dropped below 7.0% (53 mmol/mol) the year after. CONCLUSIONS In patients with type 2 diabetes treated in primary care, strict glycaemic control can be maintained with SUs used as add-on therapy to metformin, without the offset of relevant weight changes.
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Affiliation(s)
| | - Raiza Wever
- Diabetes Centre, Isala, Zwolle, The Netherlands
| | - Nanne Kleefstra
- Diabetes Centre, Isala, Zwolle, The Netherlands
- Langerhans Medical Research Group, Zwolle, The Netherlands
- Department of Internal Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Sebastiaan T Houweling
- Diabetes Centre, Isala, Zwolle, The Netherlands
- Langerhans Medical Research Group, Zwolle, The Netherlands
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Kornelis J J van Hateren
- Diabetes Centre, Isala, Zwolle, The Netherlands
- Langerhans Medical Research Group, Zwolle, The Netherlands
| | - Geertruida H de Bock
- Department of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Henk J G Bilo
- Diabetes Centre, Isala, Zwolle, The Netherlands
- Department of Internal Medicine, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- Department of Internal Medicine, Isala, Zwolle, The Netherlands
| | - Klaas H Groenier
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Gijs W D Landman
- Diabetes Centre, Isala, Zwolle, The Netherlands
- Langerhans Medical Research Group, Zwolle, The Netherlands
- Department of Internal Medicine, Gelre Hospital, Apeldoorn, The Netherlands
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13
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The challenges of outcome research. Int J Clin Pharm 2016; 38:705-8. [PMID: 27039091 DOI: 10.1007/s11096-016-0293-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 03/16/2016] [Indexed: 10/22/2022]
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14
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Survival Analysis. Health Technol Assess 2015. [DOI: 10.1201/b18285-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Rocchi A, Khoudigian S, Hopkins R, Goeree R. Surrogate outcomes: experiences at the Common Drug Review. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2013; 11:31. [PMID: 24341379 PMCID: PMC3866929 DOI: 10.1186/1478-7547-11-31] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 12/10/2013] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Surrogate outcomes are a significant challenge in drug evaluation for health technology assessment (HTA) agencies. The research objectives were to: identify factors associated with surrogate use and acceptability in Canada's Common Drug Review (CDR) recommendations, and compare the CDR with other HTA or regulatory agencies regarding surrogate concerns. METHODS Final recommendations were identified from CDR inception (September 2003) to December 31, 2010. Recommendations were classified by type of outcome (surrogate, final, other) and acceptability of surrogates (determined by the presence/absence of statements of concern regarding surrogates). Descriptive and statistical analyses examined factors related to surrogate use and acceptability. For thirteen surrogate-based submissions, recommendations from international HTA and regulatory agencies were reviewed for statements about surrogate acceptability. RESULTS Of 156 final recommendations, 68 (44%) involved surrogates. The overall 'do not list' (DNL) rate was 48%; the DNL rate for surrogates was 41% (p = 0.175). The DNL rate was 64% for non-accepted surrogates (n = 28) versus 25% for accepted surrogates (odds ratio 5.4, p = 0.002). Clinical uncertainty, use of economic evidence over price alone, and a premium price were significantly associated with non-accepted surrogates. Surrogates were used most commonly for HIV, diabetes, rare diseases, cardiovascular disease and cancer. For the subset of drugs studied, other HTA agencies did not express concerns for most recommendations, while regulatory agencies frequently stated surrogate acceptance. CONCLUSIONS The majority of surrogates were accepted at the CDR. Non-accepted surrogates were significantly associated with clinical uncertainty and a DNL recommendation. There was inconsistency of surrogate acceptability across several international agencies. Stakeholders should consider collaboratively establishing guidelines on the use, validation, and acceptability of surrogates.
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Affiliation(s)
- Angela Rocchi
- Axia Research, 2068 Waterbridge Drive, Burlington, ON L7M 3W2, Canada
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16
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Análogos de incretina e inhibidores de la DPP-4: ¿qué papel desempeñan en la prevención primaria de las enfermedades cardiovasculares? REVISTA COLOMBIANA DE CARDIOLOGÍA 2013. [DOI: 10.1016/s0120-5633(13)70072-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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17
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Bo S, Castiglione A, Ghigo E, Gentile L, Durazzo M, Cavallo-Perin P, Ciccone G. Mortality outcomes of different sulphonylurea drugs: the results of a 14-year cohort study of type 2 diabetic patients. Eur J Endocrinol 2013; 169:117-26. [PMID: 23660643 DOI: 10.1530/eje-13-0299] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Available data about mortality of type 2 diabetic patients treated with different sulphonylureas are scarce and contradictory. DESIGN We evaluated the associations between all-cause and cause-specific mortality and treatments with different sulphonylureas in a retrospective cohort of type 2 diabetic patients from a diabetes clinic. METHODS All 1277 patients treated with sulphonylureas during 19961997 were enrolled: 159 patients were treated with tolbutamide, 977 glibenclamide and 141 gliclazide. The baseline data (centralised laboratory parameters, anthropometric data and presence of chronic complications) were abstracted from the clinical records. Information on vital status was collected from demographic files after 14-year follow-up. Adjusted hazard ratios (HR) were estimated with Cox (all-cause mortality) or Fine and Gray models (cause-specific mortality), including several potential confounders. RESULTS Five hundred and fifty-six patients died during the follow-up: 262 from cardiovascular causes, 158 from cancer and 136 from other causes. When compared with the glibenclamide users, the gliclazide and tolbutamide users showed a significantly lower cancer mortality (HR=0.30; 95% CI 0.16-0.55, and HR=0.48; 95% CI 0.29-0.79 respectively). These results were strongly confirmed in the 555 patients on sulphonylurea monotherapy. None of the patients who were treated with gliclazide monotherapy died from cancer during the follow-up, and the patients on tolbutamide treatment exhibited a lower cancer mortality than the glibenclamide users (HR=0.40; 95% CI 0.22-0.71). Data did not change after stratification for the duration of sulphonylurea treatment from diabetes diagnosis to the study enrollment. CONCLUSIONS Cancer mortality was markedly reduced in the patients on gliclazide and tolbutamide treatment. These results suggest additional benefits for these drugs beyond their blood glucose-lowering effect and strongly advocate for further investigation.
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Affiliation(s)
- Simona Bo
- Department of Internal Medicine, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy.
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18
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Hofmann B. Ethical challenges with welfare technology: a review of the literature. SCIENCE AND ENGINEERING ETHICS 2013; 19:389-406. [PMID: 22218998 DOI: 10.1007/s11948-011-9348-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Accepted: 12/20/2011] [Indexed: 05/31/2023]
Abstract
Demographical changes in high income counties will increase the need of health care services but reduce the number of people to provide them. Welfare technology is launched as an important measure to meet this challenge. As with all types of technologies we must explore its ethical challenges. A literature review reveals that welfare technology is a generic term for a heterogeneous group of technologies and there are few studies documenting their efficacy, effectiveness and efficiency. Many kinds of welfare technology break with the traditional organization of health care. It introduces technology in new areas, such as in private homes, and it provides new functions, e.g. offering social stimuli and entertainment. At the same time welfare technology is developed for groups that traditionally have not been extensive technology users. This raises a series of ethical questions with regard to the development and use of welfare technologies, which are presented in this review. The main challenges identified are: (1) Alienation when advanced technology is used at home, (2) conflicting goals, as welfare technologies have many stakeholders with several ends, (3) respecting confidentiality and privacy when third-party actors are involved, (4) guaranteeing equal access and just distribution, and (5) handling conflicts between instrumental rationality and care in terms of respecting dignity and vulnerability. Addressing these issues is important for developing and implementing welfare technologies in a morally acceptable manner.
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Affiliation(s)
- Bjørn Hofmann
- Center for Medical Ethics, University of Oslo, PO Box 1130, Blindern, 0318, Oslo, Norway.
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Hanefeld M, Pfützner A, Forst T, Kleine I, Fuchs W. Double-blind, randomized, multicentre, and active comparator controlled investigation of the effect of pioglitazone, metformin, and the combination of both on cardiovascular risk in patients with type 2 diabetes receiving stable basal insulin therapy: the PIOCOMB study. Cardiovasc Diabetol 2011; 10:65. [PMID: 21756323 PMCID: PMC3160877 DOI: 10.1186/1475-2840-10-65] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 07/14/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We analyzed specific effects of an add-on therapy with pioglitazone compared to metformin and their combination in patients with basal insulin treatment on biomarkers of CV risk. METHODS In this double-blind, randomized, multicentre, active comparator controlled trial, 121 patients with type 2 diabetes were enrolled. Inclusions: treatment with basal insulin, HbA(1C) 6.5%-8.5%, age 30-75 years. After glargine therapy over 2 weeks for titration towards FBG ≤ 7.8 mmol/L, patients received either (A) bid 850 mg metformin (n = 42), (B) bid 15 mg pioglitazone (n = 40), or (C) 30 mg pioglitazone plus 1.7 g metformin (n = 39) over 6 months. Matrix Metal Proteinase 9 (MMP-9) was primary objective, together with biomarkers of CV risk. RESULTS Pioglitazone (B) reduced MMP-9 versus baseline by 54.1 ± 187.1 ng/mL, with metformin (A) it was increased by 49.6 ± 336.2 ng/mL (p = 0.0345; B vs. A), and with the combination of both (C) it was decreased by 67.8 ± 231.4 ng/mL (A vs. C: p = 0.0416; B vs. C: p = 0.8695). After logarithmic transformation due to high variances the exploratory results showed significance for A vs. B (p = 0.0043) and for A vs. C (p = 0.0289).Insulin dosage was reduced by 7.3 units in group B (p < 0.0001), by 6.0 units in C (p = 0.0004), but was increased by 2.5 units (p = 0.1539) in A at follow up. Reduction in hs-CRP was significant within treatment groups for B (p = 0.0098) and C (p < 0.0001), and between the groups for A vs. C (p = 0.0124). All three single regimens reduced PAI-1. Adiponectin was significantly elevated in B and C (p < 0.0001) and between-groups. HbA(1C) was only significantly decreased in the combination group. No significant effects were observed for NFkB and PGFα. peripheral edema were seen in 11.9% vs. 40.0% vs. 20.5%, and weight change was -0.7 kg vs. +4.3 kg vs. +2.7 kg (A vs. B vs. C). CONCLUSIONS Addition of pioglitazone but not of metformin reduces MMP-9, hs-CRP and increased insulin sensitivity and adiponectin in this study. The combination of both had no additional effect on inflammation. Pioglitazone is suggested to be a rational add-on therapy to basal insulin in patients with high CV risk.
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