SGLT2 inhibitors or GLP-1 receptor agonists as second-line therapy in type 2 diabetes: patient selection and perspectives

New treatment approaches for Alzheimer's disease: preclinical studies and clinical trials centered on antidiabetic drugs

INTRODUCTION

Alzheimer's disease (AD) and type 2 diabetes mellitus (T2DM) represent two major chronic diseases that affect a large percentage of the population and share common pathogenetic mechanisms, including oxidative stress and inflammation. Considering their common mechanistic aspects, and given the current lack of effective therapies for AD, accumulating research has focused on the therapeutic potential of antidiabetic drugs in the treatment or prevention of AD.

AREAS COVERED

This review examines the latest preclinical and clinical evidence on the potential of antidiabetic drugs as candidates for AD treatment. Numerous approved drugs for T2DM, including insulin, metformin, glucagon-like peptide-1 receptor agonists (GLP-1 RA), and sodium glucose cotransporter 2 inhibitors (SGLT2i), are in the spotlight and may constitute novel approaches for AD treatment.

EXPERT OPINION

Among other pharmacologic agents, GLP-1 RA and SGLT2i have so far exhibited promising results as novel treatment approaches for AD, while current research has centered on deciphering their action on the central nervous system (CNS). Further investigation is crucial to reveal the most effective pharmacological agents and their optimal combinations, maximize their beneficial effects on neurons, and find ways to increase their distribution to the CNS.

Evaluation of Patient Factors Associated With Achieving Goal Hemoglobin A1c in Collaborative Drug Therapy Management Ambulatory Care Clinics by Clinical Pharmacists: A Retrospective Chart Review

Background: Literature has shown the positive impact pharmacists have on diabetic outcome measures through collaborative drug therapy management (CDTM). There is minimal literature evaluating characteristics and clinical factors of patients who benefit from CDTM diabetes clinics by pharmacists. Objective: Identify patient characteristics and clinical factors that may be associated with patients who reach goal hemoglobin A1c (HbA1c) of <7% at discharge by pharmacists practicing under CDTM agreements. Methods: This retrospective chart review included patients referred to pharmacist CDTM clinics for type 2 diabetes with an HbA1c goal of <7%. Data were extracted from the electronic medical record at enrollment and discharge. Results: Of the 228 patients included, 84 achieved a goal HbA1c of <7%. Factors predictive of patient success were Asian ethnicity (odds ratio [OR] = 19.32), baseline HbA1c of 7% to 7.9% (OR = 2.34), enrolled in clinic for 5 to 6 months (OR = 2.06), in-person visit every 4 to <8 weeks (OR = 3.06), not on insulin initially or at discharge (OR = 1.79, OR = 2.02), or discharged on a glucagon-like peptide-1 receptor agonist (OR = 1.83). Factors predictive of not reaching goal were Black or African American ethnicity (OR = 0.42), <5 encounters of any type (OR = 0.44), an encounter of any type every 8 weeks or more (OR = 0.08), or discharged on a sodium-glucose cotransporter-2 inhibitor (OR = 0.27). Conclusion: Several clinical and demographic factors were identified that influenced a patient's ability to reach a goal HbA1c of <7%. The results of this study may be applied to further advance pharmacist-run clinics in optimizing diabetes care for patients.

The Interplay between Non-Esterified Fatty Acids and Plasma Zinc and Its Influence on Thrombotic Risk in Obesity and Type 2 Diabetes

Thrombosis is a major comorbidity of obesity and type-2 diabetes mellitus (T2DM). Despite the development of numerous effective treatments and preventative strategies to address thrombotic disease in such individuals, the incidence of thrombotic complications remains high. This suggests that not all the pathophysiological mechanisms underlying these events have been identified or targeted. Non-esterified fatty acids (NEFAs) are increasingly regarded as a nexus between obesity, insulin resistance, and vascular disease. Notably, plasma NEFA levels are consistently elevated in obesity and T2DM and may impact hemostasis in several ways. A potentially unrecognized route of NEFA-mediated thrombotic activity is their ability to disturb Zn²⁺ speciation in the plasma. Zn²⁺ is a potent regulator of coagulation and its availability in the plasma is monitored carefully through buffering by human serum albumin (HSA). The binding of long-chain NEFAs such as palmitate and stearate, however, trigger a conformational change in HSA that reduces its ability to bind Zn²⁺, thus increasing the ion’s availability to bind and activate coagulation proteins. NEFA-mediated perturbation of HSA-Zn²⁺ binding is thus predicted to contribute to the prothrombotic milieu in obesity and T2DM, representing a novel targetable disease mechanism in these disorders.

Incretin mimetics and sodium-glucose co-transporter 2 inhibitors as monotherapy or add-on to metformin for treatment of type 2 diabetes: a systematic review and network meta-analysis

PURPOSE

Although there are many different methods of treating type 2 diabetes (T2D), it is still difficult to draw coincident conclusions concerning the efficacy and safety of different classes of new drugs, and the recommendation level of them has still kept uncertain as second anti-diabetic agents. Therefore, the aim of this study was to summarize evidence on the efficacy and safety of DPP-4is, GLP-1RAs and SGLT-2is as monotherapy or add-on to metformin (Met) for treatment of T2D.

MATERIALS AND METHODS

We searched PubMed, Embase, Cochrane library and ClinicalTrials.gov for relevant articles in keeping with established methods using terms associated with anti-diabetic agents up to February, 2020, with no start date restriction. Weighted mean difference and risk ratios with 95% confidence intervals were calculated within traditional and network meta-analysis. Primary outcomes were the mean change in hemoglobin A1c (HbA1c), fasting plasma glucose (FPG) change and the frequency of hypoglycemic events from baseline after 12 weeks of treatment.

RESULTS

In total, 64 eligible studies comprising 37,780 patients and 7 treatment strategies were included. The results of primary outcomes showed that GLP-1RAs were significantly more effective than DPP-4is or SGLT-2is in reducing HbA1c when add-on to Met. For FPG, both GLP-1RAs and SGLT-2is significantly reduced FPG compared with DPP-4is whether add-on to Met or not. For hypoglycemia, monotherapy has a lower risk than combination therapy except for SGLT-2is. Ranking probability analysis indicated that GLP-1RAs and SGLT-2is, respectively, reduced HbA1c and FPG most when add-on to Met. Meanwhile, GLP-1RAs took the lowest risk to induce the hypoglycemia, whereas GLP-1RAs plus Met the highest.

CONCLUSIONS

Both GLP-1RAs and SGLT-2is have their own advantages in efficacy and safety. Monotherapy is beneficial for reducing the risk of hypoglycemia. The recommendation should be a patient-centered approach when selecting treatment choices.

Associations of Intensive Lifestyle Intervention in Type 2 Diabetes With Health Care Use, Spending, and Disability: An Ancillary Study of the Look AHEAD Study

IMPORTANCE

Intensive lifestyle interventions focused on diet and exercise can reduce weight and improve diabetes management. However, the long-term effects on health care use and spending are unclear, especially for public payers.

OBJECTIVE

To estimate the association of effective intensive lifestyle intervention for weight loss with long-term health care use and Medicare spending.

DESIGN, SETTING, AND PARTICIPANTS

This ancillary study used data from the Look AHEAD randomized clinical trial, which randomized participants with type 2 diabetes to an intensive lifestyle intervention or control group (ie, diabetes support and education), provided ongoing intervention from 2001 to 2012, and demonstrated improved diabetes management and reduced health care costs during the intervention. This study compared Medicare data between study arms from 2012 to 2015 to determine whether the intervention was associated with persistent reductions in health care spending.

EXPOSURE

Starting in 2001, Look AHEAD's intervention group participated in sessions with lifestyle counselors, dieticians, exercise specialists, and behavioral therapists with the goal of reducing weight 7% in the first year. Sessions occurred weekly in the first 6 months of the intervention and decreased over the intervention period. The controls participated in periodic group education sessions that occurred 3 times per year in the first year and decreased to 1 time per year later in the trial.

MAIN OUTCOMES AND MEASURES

Outcomes included total Medicare spending, Part D prescription drug costs, Part A and Part B Medicare spending, hospital admissions, emergency department visits, and disability-related Medicare eligibility.

RESULTS

This study matched Medicare administrative records for 2796 Look AHEAD study participants (54% of 5145 participants initially randomized and 86% of 3246 participants consenting to linkages). Linked intervention and control participants were of a similar age (mean [SD] age, 59.6 [5.4] years vs 59.6 [5.5] years at randomization) and sex (818 [58.1%] women vs 822 [59.3%] women). There was no statistically significant difference in total Medicare spending between groups (difference, -$133 [95% CI, -$1946 to $1681]; P = .89). In the intervention group, compared with the control group, there was statistically significantly higher Part B spending (difference, $513 [95% CI, $70 to $955]; P = .02) but lower prescription drug costs (difference, -$803 [95% CI, -$1522 to -$83]; P = .03).

CONCLUSIONS AND RELEVANCE

This ancillary study of a randomized clinical trial found that reductions in health care use and spending associated with an intensive lifestyle intervention for type 2 diabetes diminished as participants aged. Intensive lifestyle interventions may need to be sustained to reduce long-term health care spending.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03952728.

Design, Synthesis, and Evaluation of a Series of Novel Super Long-Acting DPP-4 Inhibitors for the Treatment of Type 2 Diabetes

In the present work, a novel series of trifluoromethyl-substituted tetrahydropyran derivatives were rationally designed and synthesized as potent DPP-4 inhibitors with significantly improved duration time of action over current commercially available DPP-4 inhibitors. The incorporation of the trifluoromethyl group on the 6-position of the tetrahydropyran ring of omarigliptin with the configuration of (2R,3S,5R,6S) not only significantly improves the overall pharmacokinetic profiles in mice but also maintains comparable DPP-4 inhibition activities. Further preclinical development of compound 2 exhibited its extraordinary efficacy in vivo and good safety profile. Clinical studies of compound 2 (Haisco HSK7653) are now ongoing in China, which revealed that inhibitor 2 could serve as an efficient candidate with a once-biweekly therapeutic regimen.

Mining treatment patterns of glucose-lowering medications for type 2 diabetes in the Netherlands

RATIONALE AND OBJECTIVES

Different classes of glucose-lowering medications are used for patients with type 2 diabetes mellitus (T2DM) management. It is unclear how often these medications are prescribed in clinical practice. In this study, we aimed to describe treatment patterns of glucose-lowering medications in patients with T2DM in the Netherlands.

METHODS

We studied a cohort of 73 819 patients with T2DM, aged ≥45 years with a first prescription for oral glucose-lowering medication between 2011 and 2017. We used the NControl database with dispensing data from 800 pharmacies in the Netherlands. Prevalence of each glucose-lowering medication class during 6 years after the index date was calculated. Using SQL Server, we identified stepwise patterns of medication prescription in this population.

FINDINGS

During the study period, prevalence of biguanides (BIGU) decreased from 95.6% to 80.8% and use of sulfonylureas (SU) increased from 27.3% to 42.3%. 55.2% of all patients only received BIGUs, 19.1% of all patients started on BIGUs but switched to BIGU +SU. 13.5% of patients with T2DM initiated insulins, on average 532 days (almost 18 months) after the index date.

CONCLUSIONS

Our findings showed that in the Netherlands, medication treatment in patients with T2DM is mainly consistent with the clinical guidelines in the Netherlands during the study period.

Long-term safety and efficacy of the sodium-glucose cotransporter 2 inhibitor, tofogliflozin, added on glucagon-like peptide-1 receptor agonist in Japanese patients with type 2 diabetes mellitus: A 52-week open-label, multicenter, post-marketing clinical study

AIMS/INTRODUCTION

Tofogliflozin is a potent and highly selective sodium-glucose cotransporter 2 inhibitor that is currently used to treat patients with type 2 diabetes mellitus. The aim of the present study was to evaluate the safety and efficacy of tofogliflozin add-on to glucagon-like peptide-1 (GLP-1) receptor agonist monotherapy.

MATERIALS AND METHODS

In this 52-week, prospective, multicenter, single arm, post-marketing clinical study, Japanese patients who had already been receiving GLP-1 receptor agonist monotherapy for ≥8 weeks, glycated hemoglobin ≥7.0 and <10.5%, and body mass index ≥18.5 and <35.0 kg/m2 were enrolled. Tofogliflozin 20 mg was orally administered once daily for 52 weeks with GLP-1 receptor agonist. Primary end-points were safety and change in glycated hemoglobin from baseline to week 52. Safety was assessed on the basis of the adverse events. Changes from baseline in fasting plasma glucose, bodyweight, blood pressure, uric acid and lipid parameters were assessed as secondary efficacy end-points.

RESULTS

Of the 67 patients enrolled, 63 patients completed the study. Overall, 26 adverse drug reactions occurred in 17 patients (25.4%). Adverse drug reactions with a frequency of two or more patients (3.0%) were constipation, thirst, dehydration and pollakiuria. Hypoglycemia (n = 1) was limited. With the addition of tofogliflozin to GLP-1 receptor agonist, the subsequent mean (standard deviation) reduction in glycated hemoglobin was -0.6% (1.0%; P < 0.0001). Fasting plasma glucose, bodyweight and blood pressure were significantly improved.

CONCLUSIONS

Tofogliflozin add-on to GLP-1 receptor agonist monotherapy is an effective treatment option with an acceptable safety profile.

Sodium glucose cotransporter (SGLT)-2 inhibitors: Do we need them for glucose-lowering, for cardiorenal protection or both?

Sodium glucose cotransporter (SGLT)-2 inhibitors are the newest addition to our treatment armamentarium for the management of hyperglycemia in type 2 diabetes. Glucose-lowering per se reduces the risk of microvascular complications, but not the risk of cardiovascular disease, including heart failure and cardiovascular mortality. Also, even when embedded in optimal cardiovascular prevention, a large residual risk remains with respect to progression of diabetic kidney disease. SGLT-2 inhibitors lower blood glucose levels by inducing glucosuria. Through various proposed mechanisms, among which diuretic and natriuretic effects, SGLT-2 inhibitors decrease heart failure hospitalization, reduce cardiovascular mortality, and mitigate progression of diabetic kidney disease. In this perspective, we will discuss the glucose-lowering and other protective effects of SGLT-2 inhibitors on the cardiorenal axis, both in primary and secondary prevention. By comparing the glycemic and pleiotropic effects of these agents to other glucose-lowering drugs, we will address questions around whether SGLT-2 inhibitors should be considered primarily as glucose-lowering agents, cardiorenal drugs or both.

SGLT2 inhibitors as add on therapy in type 2 diabetes: a real world study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a progressive chronic disease associated with severe microvascular and macrovascular complications. Our aim is to assess the real world effectiveness of SGT" inhibitors in achieving metabolic therapeutic goals.

METHODS

A retrospective, observational study. Inclusion criteria for patients were a previous diagnosis of type 2 diabetes mellitus, age > 18 years, patients receiving either dapagliflozin 10 mg and/or canagliflozin 300 mg. We excluded pregnant patients, patients with type 1 diabetes mellitus and acute metabolic complications of diabetes. Patients included in the analysis were enrolled in a health plan at least 6 months prior to the index date (baseline period) and in the 6 months following the index date (follow-up period). Achievement of glycated hemoglobin goals were established as <7%.

RESULTS

We screened 2870 Mexican patients; 288 (10.03% received SGLT2 inhibitors). Mean age for both groups of patients was 57.68 ± 11.06 years. The dapagliflozin control rate was 19.56% and the canagliflozin control rate 18.96%. Monotherapy with SGLT2 inhibitors was used in 21 patients (6.25%). Overall HbA1c goals were met in 56 patients (19.44%) with similar results with dapagliflozin or canagliflozin. The combination of SGLT2 inhibitors and sulfonylureas had the highest control rate (30.30%) compared to other regimens. Monotherapy was present in 6.25%. Insulin requirement was associated with poor control (2.8% vs. 18.05%, P < 0.05, 95% CI [0.07, 0.84]). Combination therapy with DPP4 inhibitors was associated with better control (P < 0.05, 95% CI, [1.10, 3.92]).

CONCLUSION

No difference between the drugs was observed. Real-world effectiveness data of SGLT2 inhibitors show that the percentage of patients reaching metabolic goals is low. SLGT2 inhibitors were used more frequently as combined therapy.

ENOblock, a unique small molecule inhibitor of the non-glycolytic functions of enolase, alleviates the symptoms of type 2 diabetes

Type 2 diabetes mellitus (T2DM) significantly impacts on human health and patient numbers are predicted to rise. Discovering novel drugs and targets for treating T2DM is a research priority. In this study, we investigated targeting of the glycolysis enzyme, enolase, using the small molecule ENOblock, which binds enolase and modulates its non-glycolytic ‘moonlighting’ functions. In insulin-responsive cells ENOblock induced enolase nuclear translocation, where this enzyme acts as a transcriptional repressor. In a mammalian model of T2DM, ENOblock treatment reduced hyperglycemia and hyperlipidemia. Liver and kidney tissue of ENOblock-treated mice showed down-regulation of known enolase target genes and reduced enolase enzyme activity. Indicators of secondary diabetic complications, such as tissue apoptosis, inflammatory markers and fibrosis were inhibited by ENOblock treatment. Compared to the well-characterized anti-diabetes drug, rosiglitazone, ENOblock produced greater beneficial effects on lipid homeostasis, fibrosis, inflammatory markers, nephrotoxicity and cardiac hypertrophy. ENOblock treatment was associated with the down-regulation of phosphoenolpyruvate carboxykinase and sterol regulatory element-binding protein-1, which are known to produce anti-diabetic effects. In summary, these findings indicate that ENOblock has potential for therapeutic development to treat T2DM. Previously considered as a ‘boring’ housekeeping gene, these results also implicate enolase as a novel drug target for T2DM.