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Goyal A, Singh H, Sehgal VK, Jayanthi CR, Munshi R, Bairy KL, Kumar R, Kaushal S, Kakkar AK, Ambwani S, Goyal C, Mazumdar G, Adhikari A, Das N, Stephy DJ, Thangaraju P, Dhasmana DC, Rehman SU, Chakrabarti A, Bhandare B, Badyal DK, Kaur I, Chandrashekar K, Singh J, Dhamija P, Sarangi SC, Gupta YK. Impact of regulatory spin of pioglitazone on prescription of antidiabetic drugs among physicians in India: A multicentre questionnaire-based observational study. Indian J Med Res 2018; 146:468-475. [PMID: 29434060 PMCID: PMC5819028 DOI: 10.4103/ijmr.ijmr_1416_15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Background & objectives: Pioglitazone was suspended for manufacture and sale by the Indian drug regulator in June 2013 due to its association with urinary bladder carcinoma, which was revoked within a short period (July 2013). The present questionnaire-based nationwide study was conducted to assess its impact on prescribing behaviour of physicians in India. Methods: Between December 2013 and March 2014, a validated questionnaire was administered to physicians practicing diabetes across 25 centres in India. Seven hundred and forty questionnaires fulfilling the minimum quality criteria were included in the final analysis. Results: Four hundred and sixteen (56.2%) physicians prescribed pioglitazone. Of these, 281 used it in less than the recommended dose of 15 mg/day. Most physicians (94.3%) were aware of recent regulatory events. However, only 333 (44.8%) changed their prescribing pattern. Seventeen of the 416 (4.1%) physicians who prescribed pioglitazone admitted having come across at least one type 2 diabetes mellitus patient (T2DM) who had urinary bladder carcinoma, and of these 13 said that it was in patients who took pioglitazone for a duration of more than two years. Only 7.8 per cent of physicians (n=58) categorically advocated banning pioglitazone, and the rest opined for its continuation or generating more evidence before decision could be taken regarding its use in T2DM. Interpretation & conclusions: Majority of the physicians though were aware of the regulatory changes with regard to pioglitazone, but their prescribing patterns were not changed for this drug. However, it was being used at lower than the recommended dose. There is a need for generating more evidence through improved pharmacovigilance activities and large-scale population-based prospective studies regarding the safety issues of pioglitazone, so as to make effectual risk-benefit analysis for its continual use in T2DM.
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Affiliation(s)
- Aman Goyal
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
| | - Harmanjit Singh
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
| | | | - C R Jayanthi
- Department of Pharmacology, Bangalore Medical College & Research Institute, Bengaluru, India
| | - Renuka Munshi
- Department of Clinical Pharmacology, TN Medical College & BYL Nair Hospital, Mumbai, India
| | - K Laxminarayana Bairy
- Department of Pharmacology, Manipal Centre for Clinical Research, Kasturba Medical College, Manipal, India
| | - Rakesh Kumar
- Department of Pharmacology, Punjab Institute of Medical Sciences, Jalandhar, India
| | - Sandeep Kaushal
- Department of Pharmacology, Dayanand Medical College & Hospital, Ludhiana, India
| | - Ashish Kumar Kakkar
- Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, India
| | - Sneha Ambwani
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, India
| | - Chhaya Goyal
- Department of Pharmacology, SAIMS Medical College & PG Institute, Indore, India
| | | | - Anjan Adhikari
- Department of Pharmacology, R.G. Kar Medical College, Kolkata, India
| | - Nina Das
- Department of Pharmacology, NRS Medical College, Kolkata, India
| | - Divya John Stephy
- Department of Pharmacology, Government Kilpauk Medical College, Chennai, India
| | - Pugazhenthan Thangaraju
- Department of Pharmacology, Central Leprosy Teaching & Research Institute, Chengalpattu, India
| | - D C Dhasmana
- Department of Pharmacology, Himalayan Institute of Medical Sciences, Dehradun, India
| | - Shakil U Rehman
- Department of Pharmacology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Amit Chakrabarti
- Department of Pharmacology, Regional Occupational Health Centre, National Institute of Occupational Health, Kolkata, India
| | - Basavaraj Bhandare
- Department of Pharmacology, Rajarajeswari Medical College & Hospital, Bengaluru, India
| | | | - Inderpal Kaur
- Department of Pharmacology, Government Medical College. Amritsar, India
| | - K Chandrashekar
- Department of Pharmacology, Chettinad Hospital & Research Institute, Chennai, India
| | - Jagjit Singh
- Department of Pharmacology, Government Medical College & Hospital, Chandigarh, India
| | - Puneet Dhamija
- Department of Pharmacology, All India Institute of Medical Sciences, Rishikesh, India
| | | | - Yogendra Kumar Gupta
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
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Pharmacodynamics, efficacy and safety of sodium-glucose co-transporter type 2 (SGLT2) inhibitors for the treatment of type 2 diabetes mellitus. Drugs 2015; 75:33-59. [PMID: 25488697 DOI: 10.1007/s40265-014-0337-y] [Citation(s) in RCA: 358] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Inhibitors of sodium-glucose co-transporter type 2 (SGLT2) are proposed as a novel approach for the management of type 2 diabetes mellitus (T2DM). Several compounds are already available in many countries (dapagliflozin, canagliflozin, empagliflozin and ipragliflozin) and some others are in a late phase of development. The available SGLT2 inhibitors share similar pharmacokinetic characteristics, with a rapid oral absorption, a long elimination half-life allowing once-daily administration, an extensive hepatic metabolism mainly via glucuronidation to inactive metabolites, the absence of clinically relevant drug-drug interactions and a low renal elimination as parent drug. SGLT2 co-transporters are responsible for reabsorption of most (90 %) of the glucose filtered by the kidneys. The pharmacological inhibition of SGLT2 co-transporters reduces hyperglycaemia by decreasing renal glucose threshold and thereby increasing urinary glucose excretion. The amount of glucose excreted in the urine depends on both the level of hyperglycaemia and the glomerular filtration rate. Results of numerous placebo-controlled randomised clinical trials of 12-104 weeks duration have shown significant reductions in glycated haemoglobin (HbA1c), resulting in a significant increase in the proportion of patients reaching HbA1c targets, and a significant lowering of fasting plasma glucose when SGLT2 inhibitors were administered as monotherapy or in addition to other glucose-lowering therapies including insulin in patients with T2DM. In head-to-head trials of up to 2 years, SGLT2 inhibitors exerted similar glucose-lowering activity to metformin, sulphonylureas or sitagliptin. The durability of the glucose-lowering effect of SGLT2 inhibitors appears to be better; however, this remains to be more extensively investigated. The risk of hypoglycaemia was much lower with SGLT2 inhibitors than with sulphonylureas and was similarly low as that reported with metformin, pioglitazone or sitagliptin. Increased renal glucose elimination also assists weight loss and could help to reduce blood pressure. Both effects were very consistent across the trials and they represent some advantages for SGLT2 inhibitors when compared with other oral glucose-lowering agents. The pharmacodynamic response to SGLT2 inhibitors declines with increasing severity of renal impairment, and prescribing information for each SGLT2 inhibitor should be consulted regarding dosage adjustments or restrictions in moderate to severe renal dysfunction. Caution is also recommended in the elderly population because of a higher risk of renal impairment, orthostatic hypotension and dehydration, even if the absence of hypoglycaemia represents an obvious advantage in this population. The overall effect of SGLT2 inhibitors on the risk of cardiovascular disease is unknown and will be evaluated in several ongoing prospective placebo-controlled trials with cardiovascular outcomes. The impact of SGLT2 inhibitors on renal function and their potential to influence the course of diabetic nephropathy also deserve more attention. SGLT2 inhibitors are generally well-tolerated. The most frequently reported adverse events are female genital mycotic infections, while urinary tract infections are less commonly observed and generally benign. In conclusion, with their unique mechanism of action that is independent of insulin secretion and action, SGLT2 inhibitors are a useful addition to the therapeutic options available for the management of T2DM at any stage in the natural history of the disease. Although SGLT2 inhibitors have already been extensively investigated, further studies should even better delineate the best place of these new glucose-lowering agents in the already rich armamentarium for the management of T2DM.
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Doggrell SA. Not so critical appraisal of dapagliflozin. Patient Prefer Adherence 2014; 8:1101-4. [PMID: 25170255 PMCID: PMC4144842 DOI: 10.2147/ppa.s68465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Sheila A Doggrell
- School of Biomedical Science, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
- Correspondence: Sheila A Doggrell, School of Biomedical Science, Faculty of Health, Queensland University of Technology, GPO 2434, QLD 4002, Australia, Email
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