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Das AK, Saboo B, Chawla R, Aravind SR, Rajput R, Singh AK, Mukherjee JJ, Jhingan A, Shah P, Deshmukh V, Kale S, Jaggi S, Sridhar GR, Dhediya R, Gaurav K. Time to reposition sulfonylureas in type 2 diabetes management in Indian context: A pragmatic practical approach. Int J Diabetes Dev Ctries 2023:1-19. [PMID: 37360324 PMCID: PMC10113130 DOI: 10.1007/s13410-023-01192-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 03/20/2023] [Indexed: 06/28/2023] Open
Abstract
Sulfonylureas (SU) continue to be a vital therapeutic category of oral hypoglycemic agents (OHAs) for the management of type 2 diabetes mellitus (T2DM). Physicians consider modern SU (gliclazide and glimepiride) as "safe and smart" choices for T2DM management. The presence of multiple international guidelines and scarcity of a national guideline may contribute to the challenges faced by few physicians in choosing the right therapeutic strategy. The role of SU in diabetes management is explicit, and the present consensus aims to emphasize the benefits and reposition SU in India. This pragmatic, practical approach aims to define expert recommendations for the physicians to improve caregivers' knowledge of the management of T2DM, leading to superior patient outcomes.
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Affiliation(s)
- Ashok Kumar Das
- Department of Endocrinology and Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Banshi Saboo
- Department of Diabetology, DIA-CARE, Ahmedabad, India
| | | | - S. R. Aravind
- Department of Medicine, Diacon Hospital, Bengaluru, India
| | - Rajesh Rajput
- Department of Endocrinology, PGIMS, Rohtak, Haryana India
| | | | - J. J. Mukherjee
- Department of Endocrinology and Diabetes, Apollo Gleneagles Hospital, Kolkata, India
| | - Ashok Jhingan
- Department of Diabetology, Delhi Diabetes Education and Research Foundation, New Delhi, India
| | - Parag Shah
- Department of Endocrinology and Diabetes, Gujarat Endocrine Centre, Ahmedabad, India
| | - Vaishali Deshmukh
- Department of Endocrinology, Deshmukh Clinic and Deenanath Mangeshkar Hospital and Research Centre, Pune, India
| | - Shailaja Kale
- Dr Shailaja Kale’s Diabetes & Speciality Clinic, Pune, India
| | | | | | - Rajnish Dhediya
- Department of Medical Affairs, Dr Reddy’s Laboratories Ltd, Hyderabad, Telangana India
| | - Kumar Gaurav
- Department of Medical Affairs, Dr Reddy’s Laboratories Ltd, Hyderabad, Telangana India
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2
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Scheen AJ. Clinical pharmacology of antidiabetic drugs: What can be expected of their use? Presse Med 2023; 52:104158. [PMID: 36565754 DOI: 10.1016/j.lpm.2022.104158] [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] [Received: 11/07/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
The pharmacotherapy of type 2 diabetes mellitus (T2DM) has markedly evolved in the last two decades. Classical antidiabetic agents (sulphonylureas, metformin, insulin) are now in competition with new glucose-lowering medications. Alpha-glucosidase inhibitors and thiazolidinediones (glitazones) were not able to replace older agents, because of insufficient efficacy and/or poor tolerability/safety. In contrast, incretin-based therapies, both dipeptidyl peptidase-4 inhibitors (DPP-4is or gliptins, oral agents) and glucagon-like peptide-1 receptor agonists (GLP-1RAs, subcutaneous injections) are a major breakthrough in the management of T2DM. Because they are not associated with hypoglycaemia and weight gain, DPP-4is tend to replace sulphonylureas as add-on to metformin while GLP-1RAs tend to replace basal insulin therapy after failure of oral therapies. Furthermore, placebo-controlled cardiovascular outcome trials demonstrated neutrality for DPP-4is, but cardiovascular protection for GLP-1RAs in patients with T2DM at high cardiovascular risk. More recently sodium-glucose cotransporter 2 inhibitors (SGLT2is or gliflozins, oral agents) also showed cardiovascular protection, especially a reduction in hospitalization for heart failure, as well as a renal protection in patients with and without T2DM, at high cardiovascular risk, with established heart failure and/or with chronic kidney disease. Thus, GLP-1RAs and SGLT2is are now considered as preferred drugs in T2DM patients with or at high risk of atherosclerotic cardiovascular disease whereas SGLT2is are more specifically recommended in patients with or at risk of heart failure and renal (albuminuric) disease. The management of T2DM is moving from a glucocentric approach to a broader strategy focusing on all risk factors, including overweight/obesity, and to an organ-disease targeted personalized approach.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium; Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
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Abozaid OAR, El-Sonbaty SM, Hamam NMA, Farrag MA, Kodous AS. Chitosan-Encapsulated Nano-selenium Targeting TCF7L2, PPARγ, and CAPN10 Genes in Diabetic Rats. Biol Trace Elem Res 2023; 201:306-323. [PMID: 35237941 PMCID: PMC9823051 DOI: 10.1007/s12011-022-03140-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 01/26/2022] [Indexed: 01/11/2023]
Abstract
This study investigates the antidiabetic and antioxidant potential of chitosan-encapsulated selenium nanoparticles in streptozotocin-induced diabetic model. Glibenclamide was used as a reference antidiabetic drug. Forty-eight adult male Wistar rats were used along the study and divided equally into 6 groups of (I) normal control, (II) chitosan-encapsulated selenium nanoparticles (CTS-SeNPs), (III) glibenclamide, (IV) streptozotocin (STZ), (V) STZ + CTS-SeNPs, and (VI) STZ + Glib. The animals were sacrificed on the 35th day of the experiment. Serum glucose, insulin, IGF-1, ALT, AST, CK-MB, oxidative stress, lipid profile, and inflammatory parameters were subsequently assessed. Also, the expression level of TCF7L2, CAPN10, and PPAR-γ genes were evaluated using qPCR. In addition, histopathological studies on pancreatic tissue were carried out. The results revealed that STZ induced both diabetes and oxidative stress in normal rats, manifested by the significant changes in the studied parameters and in the physical structure of pancreatic tissue. Oral administration of CTS-SeNPs or Glib results in a significant amelioration of the levels of serum fasting blood glucose, insulin, IGF-1, AST, ATL, and CK-MB as compared with STZ-induced diabetic rats. CTS-SeNPs and Glib diminished the level of lipid peroxidation, increased total antioxidant capacity level, as well as possessed strong inhibition against serum α-amylase and α-glucosidase activities. Diabetic animals received CTS-SeNPs, or Glib demonstrated a significant (p < 0.05) decrease in the expression level of TCF7L2 and CAPN10 genes with a significant increase in the expression level of PPAR-γ gene, compared to STZ group. The above findings clarify the promising antidiabetic and antioxidant effect of CTS-SeNPs, recommending its inclusion in the currently used protocols for the treatment of diabetes and in the prevention of its related complications.
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Affiliation(s)
- Omayma A. R. Abozaid
- Clinical Biochemistry Department, Faculty of Veterinary Medicine, Benha University, Moshtohor, Egypt
| | - Sawsan M. El-Sonbaty
- Radiation Microbiology Department, National Center for Radiation Research and Technology, Egyptian Atomic Energy Authority, Cairo, Egypt
| | - Neama M. A. Hamam
- Clinical Biochemistry Department, Faculty of Veterinary Medicine, Benha University, Moshtohor, Egypt
| | - Moustafa A. Farrag
- Radiation Biology Department, National Center for Radiation Research and Technology, Egyptian Atomic Energy Authority, Cairo, Egypt
| | - Ahmad S. Kodous
- Radiation Biology Department, National Center for Radiation Research and Technology, Egyptian Atomic Energy Authority, Cairo, Egypt
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Khunti K, Charbonnel B, Cooper A, Gomes MB, Ji L, Leigh P, Nicolucci A, Rathmann W, Shestakova MV, Siddiqui A, Tang F, Watada H, Chen H. Associations between second-line glucose-lowering combination therapies with metformin and HbA1c, body weight, quality of life, hypoglycaemic events and glucose-lowering treatment intensification: The DISCOVER study. Diabetes Obes Metab 2021; 23:1823-1833. [PMID: 33852202 DOI: 10.1111/dom.14400] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/29/2021] [Accepted: 04/08/2021] [Indexed: 12/20/2022]
Abstract
AIM To explore the effects of second-line combination therapies with metformin on body weight, HbA1c and health-related quality of life, as well as the risks of hypoglycaemia and further treatment intensification in the DISCOVER study, a 3-year, prospective, global observational study of patients with type 2 diabetes initiating second-line glucose-lowering therapy. MATERIALS AND METHODS Adjusted changes from baseline in weight, HbA1c and 36-item Short Form Health Survey version 2 (SF-36v2) summary scores at 6, 12, 24 and 36 months were assessed using linear mixed models. Risk of hypoglycaemia and further intensification were assessed using interval censored analyses. RESULTS At baseline, 7613 patients received metformin in combination with a sulphonylurea (SU; 40.9%), a dipeptidyl peptidase-4 (DPP-4) inhibitor (48.3%), a sodium-glucose co-transporter-2 (SGLT-2) inhibitor (8.3%) or a glucagon-like peptide-1 (GLP-1) receptor agonist (2.4%). After 36 months, all combinations showed similar reductions in HbA1c (0.8%-1.0%), however, metformin plus a DPP-4 inhibitor, an SGLT-2 inhibitor or a GLP-1 receptor agonist was associated with greater weight loss (1.9, 2.9 and 5.0 kg, respectively) than metformin plus an SU (1.3 kg, P < .0001). Proportions of further treatment intensification were similar across combinations (19.9%-26.2%). Patients prescribed metformin plus an SU more often reported one or more hypoglycaemic events (11.9%) than other combinations (3.9%-6.4%, P < .0001). SF-36v2 summary scores were typically lowest among patients prescribed metformin and an SU. CONCLUSIONS Combinations of metformin with an SU were associated with the lowest weight reduction, highest risk of hypoglycaemia and lower SF-36v2 scores.
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Affiliation(s)
| | | | | | | | - Linong Ji
- Peking University People's Hospital, Beijing, China
| | | | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany
| | - Marina V Shestakova
- Endocrinology Research Center, Diabetes Institute, Moscow, Russian Federation
| | | | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Hirotaka Watada
- Graduate School of Medicine, Juntendo University, Tokyo, Japan
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Strojek K, Pandey AS, Dell V, Sisson M, Wang S, Huyck S, Liu J, Gantz I. Efficacy and Safety of Ertugliflozin in Patients With Diabetes Mellitus Inadequately Controlled by Sulfonylurea Monotherapy: a Substudy of VERTIS CV. Diabetes Ther 2021; 12:1175-1192. [PMID: 33694093 PMCID: PMC7994479 DOI: 10.1007/s13300-021-01018-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/30/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Sulfonylureas (SU) are commonly used antihyperglycemic agents. VERTIS CV was the cardiovascular outcome study for the sodium-glucose cotransporter 2 inhibitor ertugliflozin. Enrollment of patients in VERTIS CV occurred in two sequential cohorts (Cohort 1 and Cohort 2). METHODS This substudy assessed the efficacy and safety of adding ertugliflozin to SU monotherapy. The primary endpoint was the change in HbA1c from baseline at 18 weeks. RESULTS Among the 8246 patients who were randomized in VERTIS CV, 157 patients in Cohort 1 and 135 patients in Cohort 2 were on SU monotherapy at baseline. In the prespecified analysis (Cohort 1 only), the least squares (LS) mean HbA1c change from baseline for placebo, ertugliflozin 5 mg, and ertugliflozin 15 mg was - 0.56%, - 0.91%, and - 0.78%, respectively (placebo-adjusted LS mean [95% CI] change: - 0.35% [- 0.72%, 0.02%]; - 0.22% [- 0.60%, 0.16%] for ertugliflozin 5 and 15 mg, respectively; p > 0.05 for both). In a post-hoc analysis that included Cohorts 1 and 2 (N = 292), the LS mean HbA1c change from baseline at week 18 for placebo, ertugliflozin 5 mg, and ertugliflozin 15 mg was - 0.31%, - 0.77%, and - 0.68%, respectively (placebo-adjusted change: - 0.46% [- 0.73%, - 0.18%]; - 0.37% [- 0.66%, - 0.09%]; p = 0.001 and 0.01 for ertugliflozin 5 and 15 mg, respectively). In Cohort 1, adverse events were reported in 45.8%, 47.3%, and 25.9% of patients with placebo, ertugliflozin 5 mg, and ertugliflozin 15 mg. The incidence rates of symptomatic hypoglycemia were 0.0%, 5.5%, and 3.7%, respectively, with no cases of severe hypoglycemia. The safety profile was similar for Cohorts 1 and 2 combined. CONCLUSION The addition of ertugliflozin to SU monotherapy reduced HbA1c but did not result in significant placebo-adjusted reductions from baseline according to the prespecified primary analysis (n = 157); however, in a post-hoc analysis with a larger patient population (n = 292), significant and clinically relevant HbA1c reductions were observed. Ertugliflozin was generally well tolerated. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01986881.
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Affiliation(s)
- Krzysztof Strojek
- Department of Internal Diseases, Diabetology and Cardiometabolic Diseases, Faculty of Medical Sciences Zabrze, Medical University of Silesia, Katowice, Poland.
| | | | | | | | | | | | - Jie Liu
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - Ira Gantz
- Merck & Co., Inc., Kenilworth, NJ, USA
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Pharmacoeconomic Analysis of Sitagliptin/Metformin for the Treatment of Type 2 Diabetes Mellitus: A Cost-Effectiveness Study. Value Health Reg Issues 2021; 26:33-39. [PMID: 33798907 DOI: 10.1016/j.vhri.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/02/2020] [Accepted: 11/19/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To assess the cost-effectiveness and cost utility of sitagliptin/metformin for the treatment of type 2 diabetes mellitus compared to those of glibenclamide/metformin in a semiprivate hospital and to compare the cost-effectiveness and cost utility of sitagliptin/metformin in a semiprivate hospital to those in the public health system (PHS) of Ecuador in 2019. METHODS A cost-effectiveness study considering the probability of cardiovascular death as the outcome and quality-adjusted life-year as a measure of utility, estimating direct medical costs in US dollars by a model case from the perspective of the third payer. The results will be presented as an incremental cost-effectiveness ratio. One-way and 2-way sensitivity analyses with tornado diagrams were performed. RESULTS Direct medical costs were lower at the hospital than from the PHS in Ecuador. Considering the drugs metformin/sitagliptin, the total cost was $35.69 less in the hospital ($880.38) than from the comparator ($916.07). The highest percentage of direct medical costs corresponded to drugs (between 63.94% and 84.65%). An ICER of -$19 131.61 was obtained at the Hospital Un Canto a la Vida and -$1621.85 at PHS. In addition, the cost per quality-adjusted life-year earned was $611.11. Sensitivity analysis showed that the probability of drug use and the relative risk of cardiovascular death associated with such prescription were parameters that most affected the model. CONCLUSIONS The combination therapy metformin/sitagliptin compared to metformin/glibenclamide was shown not to be cost-effective in the Hospital Un Canto a la Vida, and highly cost-effective in the PHS.
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Wang JS, Chen H, Tang F, Sheu WHH. Associations of fear of hypoglycemia with second-line use of insulin secretagogues or insulin and subsequent glycemic control in patients with type 2 diabetes: An analysis using data from the DISCOVER study. Int J Clin Pract 2020; 74:e13485. [PMID: 32003099 DOI: 10.1111/ijcp.13485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/26/2019] [Accepted: 01/29/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Associations of fear of hypoglycemia with prescription of second-line insulin secretagogues (IS) or insulin and subsequent glycemic control in patients with type 2 diabetes were analysed using data from the DISCOVER study-a large, prospective, observational study. METHODS Patients with type 2 diabetes initiating a second-line treatment after a first-line oral therapy were enrolled. Fear of hypoglycemia was assessed using baseline Hypoglycemia Fear Survey (HFS) worry score. Glycemic control was assessed using glycated haemoglobin (HbA1c) levels at 6-month and 1-year follow-up, and HbA1c change from baseline was analysed. To examine the association of baseline HFS worry scores with second-line use of IS or insulin, a hierarchical logistic model with country as random effect was used. RESULTS A total of 6217 patients were analysed. The mean HFS worry score was 6.9 ± 11.4, while patients in the upper quartile had an HFS worry score ≥9. We divided patients into three groups according to their baseline HFS worry score (0, 1-8, ≥9). HFS worry score was associated with the use of first-line IS, but not the second-line treatment. Compared to treatments with no IS and insulin, a better HbA1c response to second-line IS or insulin was noted in patients with a baseline HFS worry score of 0 or 1-8, but not in patients with a baseline HFS worry score ≥9. CONCLUSION HFS worry score was associated with the use of first-line IS and glycemic response to second-line IS or insulin in patients with type 2 diabetes. TRIAL REGISTRATION ClinicalTrials.gov NCT02322762. Registered 23 December 2014.
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Affiliation(s)
- Jun-Sing Wang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | | | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Wayne Huey-Herng Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Medical Technology, College of Life Science, National Chung-Hsing University, Taichung, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
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Godman B, Basu D, Pillay Y, Mwita JC, Rwegerera GM, Anand Paramadhas BD, Tiroyakgosi C, Okwen PM, Niba LL, Nonvignon J, Sefah I, Oluka M, Guantai AN, Kibuule D, Kalemeera F, Mubita M, Fadare J, Ogunleye OO, Distiller LA, Rampamba EM, Wing J, Mueller D, Alfadl A, Amu AA, Matsebula Z, Kalungia A, Zaranyika T, Masuka N, Wale J, Hill R, Kurdi A, Timoney A, Campbell S, Meyer JC. Review of Ongoing Activities and Challenges to Improve the Care of Patients With Type 2 Diabetes Across Africa and the Implications for the Future. Front Pharmacol 2020; 11:108. [PMID: 32265688 PMCID: PMC7098994 DOI: 10.3389/fphar.2020.00108] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 01/28/2020] [Indexed: 12/20/2022] Open
Abstract
Background There has been an appreciable increase in the number of people in Africa with metabolic syndrome and Type 2 diabetes (T2DM) in recent years as a result of a number of factors. Factors include lifestyle changes, urbanisation, and the growing consumption of processed foods coupled with increasing levels of obesity. Currently there are 19 million adults in Africa with diabetes, mainly T2DM (95%), estimated to grow to 47 million people by 2045 unless controlled. This has a considerable impact on morbidity, mortality and costs in the region. There are a number of issues to address to reduce the impact of T2DM including improving detection rates and current access to services alongside addressing issues of adherence to prescribed medicines. There are also high rates of co-morbidities with infectious diseases such as HIV and tuberculosis in patients in Africa with T2DM that require attention. Objective Document ongoing activities across Africa to improve the care of patients with T2DM especially around issues of identification, access, and adherence to changing lifestyles and prescribed medicines. In addition, discussing potential ways forward to improve the care of patients with T2DM based on ongoing activities and experiences including addressing key issues associated with co-morbidities with infectious diseases. Our Approach Contextualise the findings from a wide range of publications including internet based publications of national approaches coupled with input from senior level government, academic and other professionals from across Africa to provide future guidance. Ongoing Activities A number of African countries are actively instigating programmes to improve the care of patients with T2DM starting with improved diagnosis. This recognises the growing burden of non-communicable diseases across Africa, which has been neglected in the past. Planned activities include programmes to improve detection rates and address key issues with diet and lifestyle changes, alongside improving monitoring of care and activities to enhance adherence to prescribed medicines. In addition, addressing potential complexities involving diabetes patients with infectious disease co-morbidities. It is too early to fully assess the impact of such activities. Conclusion There are a number of ongoing activities across Africa to improve the management of patients with diabetes including co-morbidities. However, more needs to be done considering the high and growing burden of T2DM in Africa. Ongoing research will help further benefit resource allocation and subsequent care.
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Affiliation(s)
- Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom.,Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa.,Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Health Economics Centre, University of Liverpool Management School, Liverpool, United Kingdom
| | - Debashis Basu
- Department of Public Health Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Yogan Pillay
- HIV & AIDS, TB and Maternal, Child and Women's Health, National Department of Health, Pretoria, South Africa
| | - Julius C Mwita
- Department of Internal Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Godfrey Mutashambara Rwegerera
- Department of Internal Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana.,Department of Medicine, Princess Marina Hospital, Gaborone, Botswana
| | | | - Celda Tiroyakgosi
- Botswana Essential Drugs Action Program, Ministry of Health and Wellness, Gaborone, Botswana
| | - Patrick Mbah Okwen
- Effective Basic Services (eBASE) Africa, Bamenda, Cameroon.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Loveline Lum Niba
- Effective Basic Services (eBASE) Africa, Bamenda, Cameroon.,Department of Public Health, University of Bamenda, Bambili, Cameroon
| | | | - Israel Sefah
- Department of Pharmacy, Keta Municipal Hospital, Ghana Health Service, Keta, Ghana
| | - Margaret Oluka
- Department of Pharmacology and Pharmacognosy, School of Pharmacy, University of Nairobi, Nairobi, Kenya
| | - Anastasia N Guantai
- Department of Pharmacy Practice and Policy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Dan Kibuule
- Department of Pharmacy Practice and Policy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Francis Kalemeera
- Department of Pharmacy Practice and Policy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Mwangana Mubita
- Department of Pharmacy Practice and Policy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Joseph Fadare
- Department of Pharmacology and Therapeutics, Ekiti State University, Ado-Ekiti, Nigeria.,Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | - Olayinka O Ogunleye
- Department of Pharmacology, Therapeutics and Toxicology, Lagos State University College of Medicine, Lagos, Nigeria.,Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria
| | - Larry A Distiller
- Centre for Diabetes & Endocrinology (Pty) Ltd, Johannesburg, South Africa
| | - Enos M Rampamba
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa.,Department of Pharmacy, Tshilidzini Regional Hospital, Limpopo Department Of Health, Shayandima, South Africa
| | - Jeffrey Wing
- School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Debjani Mueller
- Department of Public Health Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa.,Charlotte Maxeke Medical Research Cluster, Johannesburg, South Africa
| | - Abubakr Alfadl
- National Medicines Board, Federal Ministry of Health, Khartoum, Sudan.,Unaizah College of Pharmacy, Qassim University, Unaizah, Saudi Arabia
| | | | | | - Aubrey Kalungia
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Trust Zaranyika
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Nyasha Masuka
- Independent Health Systems Consultant, Harare, Zimbabwe
| | - Janney Wale
- Independent Consumer Advocate, Brunswick, VIC, Australia
| | - Ruaraidh Hill
- Liverpool Reviews and Implementation Group, Liverpool University, Liverpool, United Kingdom
| | - Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom.,Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
| | - Angela Timoney
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom.,NHS Lothian Director of Pharmacy, NHS Lothian, Edinburgh, United Kingdom
| | - Stephen Campbell
- Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, United Kingdom.,NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Johanna C Meyer
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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Vaughan EM, Rueda JJ, Samson SL, Hyman DJ. Reducing the Burden of Diabetes Treatment: A Review of Low-cost Oral Hypoglycemic Medications. Curr Diabetes Rev 2020; 16:851-858. [PMID: 32026779 PMCID: PMC7415714 DOI: 10.2174/1573399816666200206112318] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/24/2019] [Accepted: 01/20/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The vast majority of individuals diagnosed with diabetes are low/middle income and may have access to only three of the 11 oral hypoglycemic medications (OHMs) due to cost: metformin intermediate release (IR) or extended release (ER), sulfonylureas (glimepiride, glipizide, glyburide), and pioglitazone. Sulfonylureas and pioglitazone have had significant controversy related to potential adverse events, but it remains unclear whether these negative outcomes are class, drug, or dose-related. OBJECTIVE We conducted a narrative review of low-cost OHMs. METHODS We evaluated the maximum recommended (MAX) compared to the most effective (EFF) daily dose, time-to-peak change in HbA1c levels, and adverse events of low-cost oral hypoglycemic medications. RESULTS We found that the MAX was often greater than the EFF: metformin IR/ER (MAX: 2,550/2,000 mg, EFF: 1,500-2,000/1,500-2,000 mg), glipizide IR/ER (MAX: 40/20 mg, EFF: 20/5 mg), glyburide (MAX: 20 mg, EFF: 2.5-5.0 mg), pioglitazone (MAX: 45 mg, EFF: 45 mg). Time-to-peak change in HbA1c levels occurred at weeks 12-20 (sulfonylureas), 25-39 (metformin), and 25 (pioglitazone). Glimepiride was not associated with weight gain, hypoglycemia, or negative cardiovascular events relative to other sulfonylureas. Cardiovascular event rates did not increase with lower glyburide doses (p<0.05). Glimepiride and pioglitazone have been successfully used in renal impairment. CONCLUSION Metformin, glimepiride, and pioglitazone are safe and efficacious OHMs. Prescribing at the EFF rather than the MAX may avoid negative dose-related outcomes. OHMs should be evaluated as individual drugs, not generalized as a class, due to different dosing and adverse-event profiles; Glimepiride is the preferred sulfonylurea since it is not associated with the adverse events as others in its class.
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Affiliation(s)
- Elizabeth M Vaughan
- Division of General Internal Medicine, Department of Medicine, Baylor College of Medicine, University in Houston, Texas, TX 77030, United States
| | - Jaime J Rueda
- Division of General Internal Medicine, Department of Medicine, Baylor College of Medicine, University in Houston, Texas, TX 77030, United States
| | - Susan L Samson
- Section of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Baylor College of Medicine, University in Houston, Texas, TX 77030, United States
| | - David J Hyman
- Division of General Internal Medicine, Department of Medicine, Baylor College of Medicine, University in Houston, Texas, TX 77030, United States
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Powell WR, Christiansen CL, Miller DR. Long-term comparative safety analysis of the risks associated with adding or switching to a sulfonylurea as second-line Type 2 diabetes mellitus treatment in a US veteran population. Diabet Med 2019; 36:1384-1390. [PMID: 30343492 DOI: 10.1111/dme.13839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2018] [Indexed: 12/01/2022]
Abstract
AIM To examine the risks of all-cause mortality and cardiovascular events associated with adding vs switching to second-line therapies in a comparative safety study of people with Type 2 diabetes mellitus. METHODS We conducted a retrospective cohort study using an as-treated analysis of people served by the Veterans Health Administration who were on metformin and subsequently augmented this treatment or switched to other oral glucose-lowering treatments between 1998 and 2012. This study included 145 250 people with long follow-up. Confounding was addressed through several strategies, involving weighted propensity score models with rich confounder adjustment and strict inclusion criteria, coupled with an incident-user design. RESULTS Second-line use of sulfonylureas was related to higher mortality (hazard ratio 1.39, 95% CI 1.14, 1.70) and cardiovascular risks (hazard ratio 1.19, 95% CI 1.09, 1.30) compared with thiazolidinedione therapy. Differential hazards were associated with discontinuing or not discontinuing metformin; switching to sulfonylurea therapy was associated with a higher risk of all-cause mortality and cardiovascular events compared with all other therapies. Furthermore, add-on sulfonylurea therapy was associated with an elevated risk for both outcomes when compared with thiazolidinedione add-on therapy. CONCLUSIONS The results of the present study may inform decisions on whether to augment or discontinue metformin; when considering the long-term risks, switching to a sulfonylurea appears unfavourable compared with other therapies. Instead, adding a thiazolidinedione to existing metformin therapy appears to be superior to adding or switching to a sulfonylurea.
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Affiliation(s)
- W R Powell
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - C L Christiansen
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - D R Miller
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Department of Dermatology, Boston University School of Medicine, Boston, MA, USA
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11
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Tandon T, Dubey AK, Srivastava S, Manocha S, Arora E, Hasan N. A pharmacoeconomic analysis to compare cost-effectiveness of metformin plus teneligliptin with metformin plus glimepiride in patients of type-2 diabetes mellitus. J Family Med Prim Care 2019; 8:955-959. [PMID: 31041232 PMCID: PMC6482796 DOI: 10.4103/jfmpc.jfmpc_22_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background With the available evidence of early combined oral drug therapies being more effective in lowering blood glucose levels than maximal doses of a single drug, many clinicians are taking the aggressive approach of adding a sulfonylurea or a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin as the initial therapy in type 2 diabetes mellitus (T2DM). Pharmacotherapy for a chronic disease like diabetes has substantial economic implications for patients especially in a developing country like India. So it is important to scientifically evaluate the cost-effectiveness of these commonly practiced combination therapies in the management of T2DM. Materials and Methods This was a prospective observational randomized comparative study conducted over 8 weeks on patients of T2DM who were prescribed either of the two therapies of metformin (500 mg) plus glimepiride (1 mg) or metformin (500 mg) plus teneligliptin (20 mg). Cost-effectiveness analysis was done by calculating the expense incurred on 0.1% reduction in HbA1 c and 1 mg/dl reduction in fasting plasma glucose (FPG)/post-prandial plasma glucose (PPG) levels after 8 weeks and compared for both the groups. The same was also evaluated for differences in BMI levels. Results The cost-effectiveness for per unit reduction in HbA1c and FPG was significant in metformin plus glimepiride group as compared to the metformin plus teneligliptin group though it was comparable for both the groups for per unit PPG reduction. There was no significant change in BMI levels between the groups. Conclusion Compared to metformin plus teneligliptin, metformin plus glimepiride is a significantly cost-effective therapy when used as an initial combination therapy in patients of T2DM in lowering HbA1c and FPG.
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Affiliation(s)
- Tanya Tandon
- Department of Pharmacology, SMSR, Sharda University, NCR, Greater Noida, Uttar Pradesh, India
| | - Ashok K Dubey
- Department of Pharmacology, SMSR, Sharda University, NCR, Greater Noida, Uttar Pradesh, India
| | - Saurabh Srivastava
- Department of Medicine, SMSR, Sharda University, NCR, Greater Noida, Uttar Pradesh, India
| | - Sachin Manocha
- Department of Pharmacology, SMSR, Sharda University, NCR, Greater Noida, Uttar Pradesh, India
| | - Ekta Arora
- Department of Pharmacology, SMSR, Sharda University, NCR, Greater Noida, Uttar Pradesh, India
| | - Nazer Hasan
- Department of Pharmacology, SMSR, Sharda University, NCR, Greater Noida, Uttar Pradesh, India
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Cordiner RLM, Pearson ER. Reflections on the sulphonylurea story: A drug class at risk of extinction or a drug class worth reviving? Diabetes Obes Metab 2019; 21:761-771. [PMID: 30471177 DOI: 10.1111/dom.13596] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 11/15/2018] [Accepted: 11/20/2018] [Indexed: 01/12/2023]
Abstract
The role of sulphonylureas (SUs) in modern clinical practice poses ongoing clinical debate. With the advent of newer agents in diabetes management, there is an increasing shift away from the prescribing of SUs, but not necessarily to more effective agents. This review provides a different perspective on the debate, reflecting in depth upon the physiology of SUs, drawing on insights gained from monogenic diabetes to highlight the potential benefit of lower doses of SUs, and the probable benefit of gliclazide over most other, if not all SUs, in terms of sulphonylurea failure and cardiovascular outcomes.
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13
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Powell WR, Christiansen CL, Miller DR. Meta-Analysis of Sulfonylurea Therapy on Long-Term Risk of Mortality and Cardiovascular Events Compared to Other Oral Glucose-Lowering Treatments. Diabetes Ther 2018; 9:1431-1440. [PMID: 29808360 PMCID: PMC6064594 DOI: 10.1007/s13300-018-0443-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Among the most pressing clinical decisions in type 2 diabetes treatments are which drugs should be used after metformin is no longer sufficient, and whether sulfonylureas (SUs) should remain as a suitable second-line treatment. In this article we summarize current evidence on the long-term safety risks associated with SU therapy relative to other oral glucose-lowering therapies. METHODS The MEDLINE database and Clinicaltrials.gov were searched for observational and experimental studies comparing the safety of SUs to that of other diabetes medications in people with type 2 diabetes mellitus through December 15, 2015. Studies with at least 1 year of follow-up, which explicitly examined major cardiovascular events or death in patients who showed no evidence of serious conditions at baseline, were selected for inclusion in meta-analyses. RESULTS SU treatment was associated with an elevated risk relative to treatment with metformin (METF), thiazolidinedione (TZD), dipeptidyl peptidase-4 inhibitor (DPP-4), and glucagon-like peptide-1 (GLP-1) agonist classes, either when compared alone (as a monotherapy) or when used in combination with METF. Significant findings were almost entirely derived from nontrial data and not confirmed by smaller, efficacy designed randomized controlled trials whose effects were in the same direction but much more imprecise. CONCLUSION Although much of the evidence is derived and will continue to come from observational studies, the methodological rigor of such studies is questionable. A key challenge for evaluators is the extent to which they should incorporate evidence from study designs that are quasi-experimental.
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Affiliation(s)
- W Ryan Powell
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, USA.
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Cindy L Christiansen
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
- Department of Dermatology, Boston University School of Medicine, Boston, MA, USA
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14
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Stone JA, Houlden RL, Lin P, Udell JA, Verma S. Cardiovascular Protection in People With Diabetes. Can J Diabetes 2018; 42 Suppl 1:S162-S169. [DOI: 10.1016/j.jcjd.2017.10.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 10/17/2022]
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15
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Kalra S, Bahendeka S, Sahay R, Ghosh S, Md F, Orabi A, Ramaiya K, Al Shammari S, Shrestha D, Shaikh K, Abhayaratna S, Shrestha PK, Mahalingam A, Askheta M, A. Rahim AA, Eliana F, Shrestha HK, Chaudhary S, Ngugi N, Mbanya JC, Aye TT, Latt TS, Akanov ZA, Syed AR, Tandon N, Unnikrishnan AG, Madhu SV, Jawa A, Chowdhury S, Bajaj S, Das AK. Consensus Recommendations on Sulfonylurea and Sulfonylurea Combinations in the Management of Type 2 Diabetes Mellitus - International Task Force. Indian J Endocrinol Metab 2018; 22:132-157. [PMID: 29535952 PMCID: PMC5838894 DOI: 10.4103/ijem.ijem_556_17] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
For decades, sulfonylureas (SUs) have been important drugs in the antidiabetic therapeutic armamentarium. They have been used as monotherapy as well as combination therapy. Focus on newer drugs and concerns about the risk of severe hypoglycemia and weight gain with some SUs have led to discussion on their safety and utility. It has to be borne in mind that the adverse events associated with SUs should not be ascribed to the whole class, as many modern SUs, such as glimepiride and gliclazide modified release, are associated with better safety profiles. Furthermore, individualization of treatment, using SUs in combination with other drugs, backed with careful monitoring and patient education, ensures maximum benefits with minimal side effects. The current guidelines, developed by experts from Africa, Asia, and the Middle East, promote the safe and smart use of SUs in combination with other glucose-lowering drugs.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
| | - Silver Bahendeka
- Department of Internal Medicine, Diabetes & Endocrinology, St. Francis Hospital, Nsambya, Kampala, Uganda
| | - Rakesh Sahay
- Department of Endocrinology, Osmania Medical College, Hyderabad, Telangana, India
| | - Sujoy Ghosh
- Department of Endocrinology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Fariduddin Md
- Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Abbas Orabi
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Kaushik Ramaiya
- Department of Internal Medicine, Hindu Mandal Hospital, Dar es Salaam, Tanzania
| | | | - Dina Shrestha
- Department of Endocrinology, Norvic International Hospital and Medical College, and Hospital for Advanced Medicine and Surgery, Maharajganj, Kathmandu, Nepal
| | - Khalid Shaikh
- Department of Diabetes, Faculty of Internal Medicine, Royal Oman Police Hospital, Muscat, Oman
| | - Sachitha Abhayaratna
- Department of Pharmacology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Pradeep K. Shrestha
- Department of Medicine, Tribhuvan University Teaching Hospital, Maharajganj, Kathmandu, Nepal
| | | | | | - Aly Ahmed A. Rahim
- Department of Internal Medicine, Diabetes & Metabolism Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Fatimah Eliana
- Department of Internal Medicine, Faculty of Medicine, YARSI University, Jakarta, Indonesia
| | - Hari K. Shrestha
- Department of Internal Medicine, Kathmandu University Hospital, Dhulikhel, Nepal
| | | | - Nancy Ngugi
- Department of Endocrinology, Kenyatta National Hospital, Nairobi, Kenya
| | - Jean Claude Mbanya
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé, Yaounde, Cameroon
| | - Than Than Aye
- Department of Endocrinology, University of Medicine 2, Yangon, Myanmar
| | - Tint Swe Latt
- Department of Medicine, University of Medicine 2, Yangon, Myanmar
| | - Zhanay A. Akanov
- Center of Diabetes, Clinic of Internal Diseases, Asfendiyarov Kazakh National Medical University, Almaty, Republic of Kazakhstan
| | - Abbas Raza Syed
- Department of Endocrinology, Shaukat Khanum Hospital and Research Center, Lahore, Pakistan
| | - Nikhil Tandon
- Department of Endocrinology, Metabolism and Diabetes, All India Institute of Medical Sciences, Pune, Maharashtra, India
| | - A. G. Unnikrishnan
- Department of Endocrinology and Diabetes, Chellaram Diabetes Institute, Pune, Maharashtra, India
| | - S. V. Madhu
- Department of Medicine, University of Delhi, New Delhi, India
| | - Ali Jawa
- Department of Endocrinology, Diabetes and Metabolism, Wilshire Cardiovascular and Endocrine Center of Excellence, Lahore, Pakistan
| | - Subhankar Chowdhury
- Department of Endocrinology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Sarita Bajaj
- Department of Medicine, MLN Medical College, Allahabad, Uttar Pradesh, India
| | - Ashok Kumar Das
- Department of General Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
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Kawazu S, Kanazawa Y, Iwamoto Y, Katayama S, Origasa H, Kuzuya T. Effect of antihyperglycemic drug monotherapy to prevent the progression of mild hyperglycemia in early type 2 diabetic patients: the Japan Early Diabetes Intervention Study (JEDIS). Diabetol Int 2017; 8:350-365. [PMID: 30603341 PMCID: PMC6224919 DOI: 10.1007/s13340-017-0319-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 03/27/2017] [Indexed: 11/25/2022]
Abstract
To effectively prevent the worsening of hyperglycemia in type 2 diabetes mellitus, it is of interest to see the clinical efficacy of early introduction of pharmacotherapy in addition to lifestyle intervention which is not always easy to continue throughout life. This is a randomized unblinded comparative clinical study on suppressive effects of lifestyle intervention alone and additional monotherapies for mild hyperglycemia at an early stage of treatment-naïve type 2 diabetic patients, whose fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1c) are less than 140 mg/dl and 7.4%, respectively. The control group (group N = arm N) received conventional lifestyle intervention assisted by routine facilities, while the pharmacological intervention group (group D composed of 4 arms) was additionally treated by monotherapy with one of four kinds of oral antihyperglycemic agents i.e., sulfonylurea (SU), α-glucosidase inhibitor, biguanide and dipeptidyl peptidase-4 inhibitor. The participants were scheduled to follow up for 3 years to maintain glycemic control below primary endpoint which was defined as the first occurrence of FPG ≥140 mg/dl and HbA1c ≥7.4% simultaneously even by increasing doses of oral drug in group D, if necessary. The outcomes of occurrences of primary endpoint were not different between group N and group D composed of 4 arms during 3 years by Kaplan-Meyer plots (p = 0.405). On the other hand, ΔFPG (Δ: incremental change from baseline) and ΔHbA1c in group D significantly decreased when compared to those of group N during 3 years (p < 0.05 and p < 0.01 respectively). Significant reductions of ΔBMI were seen similarly in both groups throughout the study (p < 0.05), but did not differ between two groups. Among these 5 arms, significant decreases of ΔHbA1c were observed in three monotherapy arms of group D compared to arm N for 3 years (p < 0.05 or p < 0.01), except for arm SU in which ΔBMI and ΔHbA1c tended to increase at the latter half of the study. The final achievement rates of target HbA1c less than 7.4, 7.0 and 6.5% in all the participants tended to be higher in group D than in group N (p < 0.047 for 7.4%, but not significant for others). In conclusion, the early introduction of pharmacological monotherapy in addition to lifestyle intervention seem to suppress mild hyperglycemia with small doses of antihyperglycemic agents for 3 years, except for the use of SU drug. Although a larger scale of trial will be necessary to conclude, the early treatment with suitable monotherapy could be effective to bring and keep "safe level of glycemia".
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Affiliation(s)
- Shoji Kawazu
- The Institute for Adult Diseases, Asahi Life Foundation, 2-2-6 Nihonbashi, Bakuro-cho, Chuo-ku, Tokyo, 103-0002 Japan
| | | | - Yasuhiko Iwamoto
- The Institute for Adult Diseases, Asahi Life Foundation, 2-2-6 Nihonbashi, Bakuro-cho, Chuo-ku, Tokyo, 103-0002 Japan
| | | | - Hideki Origasa
- Department of Biostatistics and Clinical Epidemiology, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | | | - The JEDIS (Japan Early Diabetes Intervention Study) Research Group
- The Institute for Adult Diseases, Asahi Life Foundation, 2-2-6 Nihonbashi, Bakuro-cho, Chuo-ku, Tokyo, 103-0002 Japan
- Jichi Medical University, Tochigi, Japan
- Saitama Medical University, Saitama, Japan
- Department of Biostatistics and Clinical Epidemiology, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
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17
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Devarajan TV, Venkataraman S, Kandasamy N, Oomman A, Boorugu HK, Karuppiah SKP, Balat D. Comparative Evaluation of Safety and Efficacy of Glimepiride and Sitagliptin in Combination with Metformin in Patients with Type 2 Diabetes Mellitus: Indian Multicentric Randomized Trial - START Study. Indian J Endocrinol Metab 2017; 21:745-750. [PMID: 28989886 PMCID: PMC5628548 DOI: 10.4103/ijem.ijem_176_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Modern sulfonylureas like glimepiride offer effective glycemic control with extrapancreatic benefits and good tolerability. The objective of the present study was to evaluate and compare safety and efficacy of glimepiride and sitagliptin in combination with metformin in patients with type 2 diabetes mellitus (T2DM). METHODS In this open-label, randomized, comparative, multicenter study, a total of 305 T2DM patients who were either drug naïve or uncontrolled on metformin were randomized to glimepiride 1 or 2 mg/sustained-release metformin 1000 mg once daily (glimepiride group, n = 202) or sitagliptin 50 mg/metformin 500 mg twice daily (sitagliptin group, n = 103) for 12 weeks. Primary endpoint was change in glycosylated hemoglobin (HbA1c). Secondary endpoints were change in fasting plasma glucose (FPG), postprandial plasma glucose (PPG), body mass index (BMI) and to assess overall safety profile. RESULTS At 12 weeks, there was a statistically significant difference in the mean HbA1c reduction in glimepiride group (0.42%) as compared to sitagliptin group (0.30%) (P = 0.001). Mean reduction in FPG and PPG was also statistically significant in the glimepiride group as compared to the sitagliptin group (P = 0.008). There was no significant difference in terms of change in BMI (0.07 ± 0.39 kg/m2 vs. 0.08 ± 0.31 kg/m2) in glimepiride and sitagliptin groups, respectively, (P = 0.644) between both the groups. The incidences of hypoglycemic events were also comparable among both the groups. CONCLUSION In T2DM patients, glimepiride/metformin combination exhibited significant reduction in glycemic parameters as compared to sitagliptin/metformin combination. Moreover, there was no significant difference between both the groups in terms of change in BMI and incidence of hypoglycemia.
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Affiliation(s)
- T. V. Devarajan
- Consultant Physician, Apollo First Med Hospitals, Chennai, Tamil Nadu, India
| | - S. Venkataraman
- Consultant Physician and Diabetologist, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Narayanan Kandasamy
- Consultant Endocrinologist and Diabetologist, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Abraham Oomman
- Consultant Cardiologist, Apollo Hospitals, Chennai, Tamil Nadu, India
| | | | - S. K. P. Karuppiah
- Consultant Cardiologist, Apollo Speciality Hospital, Madurai, Tamil Nadu, India
| | - Dushyant Balat
- Consultant Cardiologist, Apollo Hospitals International Limited, Ahmedabad, Gujarat, India
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18
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Chang YH, Hwu DW, Chang DM, An LW, Hsieh CH, Lee YJ. Renal function preservation with pioglitazone or with basal insulin as an add-on therapy for patients with type 2 diabetes mellitus. Acta Diabetol 2017; 54:561-568. [PMID: 28331986 DOI: 10.1007/s00592-017-0983-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 03/11/2017] [Indexed: 01/11/2023]
Abstract
AIMS Clinical outcome may differ owing to the distinct pharmacological characteristics of insulin sensitizers and insulin. This study was performed to compare the metabolic and renal function changes with add-on pioglitazone treatment versus basal insulin in patients with type 2 diabetes mellitus (DM) in whom sulfonylurea and metformin regimens failed. METHODS Patients who were consecutively managed in the diabetes comprehensive program with add-on pioglitazone or detemir/glargine treatment for at least 2 years following sulfonylurea and metformin treatment failure were included. RESULTS A total of 1002 patients were enrolled (pioglitazone: 559, detemir: 264, glargine: 179). After propensity score matching, there were 105 patients with matchable baseline characteristics in each group. After a mean of 3.5 years of follow-up, the pioglitazone group showed a greater HbA1c reduction than the detemir group and the glargine group. Despite patients in all three groups exhibiting significant body weight gain, those in the pioglitazone group and the glargine group showed greater body weight increases than the patients in the detemir group (2.1, 1.6 and 0.8 kg, respectively, p < 0.05). Interestingly, Cox regression analysis indicated that patients under detemir or glargine treatment had a higher probability of CKD progression as compared with the pioglitazone group, with hazard ratios of 2.63 (95% CI 1.79-3.88) and 3.13 (95% CI 2.01-4.87), respectively. CONCLUSIONS Our study first showed that treatment with both pioglitazone and basal insulin improved glycemic control, while only pioglitazone treatment was observed to be advantageous in terms of preserving renal function when used as an add-on therapy for patients with type 2 DM in whom sulfonylurea and metformin regimens failed.
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Affiliation(s)
- Yu-Hung Chang
- Department of Internal Medicine, Lee's Endocrinology Clinic, # 130 Min-Tzu Rd, Pingtung, 90000, Taiwan.
| | - Der-Wei Hwu
- Department of Internal Medicine, Lee's Endocrinology Clinic, # 130 Min-Tzu Rd, Pingtung, 90000, Taiwan
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Dao-Ming Chang
- Department of Internal Medicine, Lee's Endocrinology Clinic, # 130 Min-Tzu Rd, Pingtung, 90000, Taiwan
| | - Ling-Wang An
- Department of Medical Education, Beijing Ruijing Diabetes Hospital, Beijing, 100078, China
| | - Chang-Hsun Hsieh
- Division of Endocrinology and Metabolism, Department of Internal MedicineNational Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Yau-Jiunn Lee
- Department of Internal Medicine, Lee's Endocrinology Clinic, # 130 Min-Tzu Rd, Pingtung, 90000, Taiwan
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19
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Affiliation(s)
- Matthew C Riddle
- Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, OR
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20
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Min JY, Griffin MR, Hung AM, Grijalva CG, Greevy RA, Liu X, Elasy T, Roumie CL. Comparative Effectiveness of Insulin versus Combination Sulfonylurea and Insulin: a Cohort Study of Veterans with Type 2 Diabetes. J Gen Intern Med 2016; 31:638-46. [PMID: 26921160 PMCID: PMC4870423 DOI: 10.1007/s11606-016-3633-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Type 2 diabetes patients often initiate treatment with a sulfonylurea and subsequently intensify their therapy with insulin. However, information on optimal treatment regimens for these patients is limited. OBJECTIVE To compare risk of cardiovascular disease (CVD) and hypoglycemia between sulfonylurea initiators who switch to or add insulin. DESIGN This was a retrospective cohort assembled using national Veterans Health Administration (VHA), Medicare, and National Death Index databases. PARTICIPANTS Veterans who initiated diabetes treatment with a sulfonylurea between 2001 and 2008 and intensified their regimen with insulin were followed through 2011. MAIN MEASURES The association between insulin versus sulfonylurea + insulin and time to CVD or hypoglycemia were evaluated using Cox proportional hazard models in a 1:1 propensity score-matched cohort. CVD included hospitalization for acute myocardial infarction or stroke, or cardiovascular mortality. Hypoglycemia included hospitalizations or emergency visits for hypoglycemia, or outpatient blood glucose measurements <60 mg/dL. Subgroups included age < 65 and ≥ 65 years and estimated glomerular filtration rate ≥ 60 and < 60 ml/min. KEY FINDINGS There were 1646 and 3728 sulfonylurea monotherapy initiators who switched to insulin monotherapy or added insulin, respectively. The 1596 propensity score-matched patients in each group had similar baseline characteristics at insulin initiation. The rate of CVD per 1000 person-years among insulin versus sulfonylurea + insulin users were 49.3 and 56.0, respectively [hazard ratio (HR) 0.85, 95 % confidence interval (CI) 0.64, 1.12]. Rates of first and recurrent hypoglycemia events per 1000 person-years were 74.0 and 100.0 among insulin users compared to 78.9 and 116.8 among sulfonylurea plus insulin users, yielding HR (95 % CI) of 0.94 (0.76, 1.16) and 0.87 (0.69, 1.10), respectively. Subgroup analysis results were consistent with the main findings. CONCLUSIONS Compared to sulfonylurea users who added insulin, those who switched to insulin alone had numerically lower CVD and hypoglycemia events, but these differences in risk were not statistically significant.
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Affiliation(s)
- Jea Young Min
- Veterans Health Administration - Tennessee Valley Healthcare System Geriatrics Research Education Clinical Center (GRECC), Health Service Research and Development Center (HSRD), Nashville, TN, USA.,Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Marie R Griffin
- Veterans Health Administration - Tennessee Valley Healthcare System Geriatrics Research Education Clinical Center (GRECC), Health Service Research and Development Center (HSRD), Nashville, TN, USA.,Department of Medicine, Vanderbilt University, Nashville, TN, USA.,Department of Health Policy, Vanderbilt University, Nashville, TN, USA
| | - Adriana M Hung
- Veterans Health Administration - Tennessee Valley Healthcare System Geriatrics Research Education Clinical Center (GRECC), Health Service Research and Development Center (HSRD), Nashville, TN, USA.,Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Carlos G Grijalva
- Veterans Health Administration - Tennessee Valley Healthcare System Geriatrics Research Education Clinical Center (GRECC), Health Service Research and Development Center (HSRD), Nashville, TN, USA.,Department of Health Policy, Vanderbilt University, Nashville, TN, USA
| | - Robert A Greevy
- Veterans Health Administration - Tennessee Valley Healthcare System Geriatrics Research Education Clinical Center (GRECC), Health Service Research and Development Center (HSRD), Nashville, TN, USA.,Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | - Xulei Liu
- Veterans Health Administration - Tennessee Valley Healthcare System Geriatrics Research Education Clinical Center (GRECC), Health Service Research and Development Center (HSRD), Nashville, TN, USA.,Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | - Tom Elasy
- Veterans Health Administration - Tennessee Valley Healthcare System Geriatrics Research Education Clinical Center (GRECC), Health Service Research and Development Center (HSRD), Nashville, TN, USA.,Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Christianne L Roumie
- Veterans Health Administration - Tennessee Valley Healthcare System Geriatrics Research Education Clinical Center (GRECC), Health Service Research and Development Center (HSRD), Nashville, TN, USA. .,Department of Medicine, Vanderbilt University, Nashville, TN, USA.
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Laudo Pardos C, Puigdevall Gallego V. [What do they offer new oral antibiotics?]. Aten Primaria 2016; 48:279-80. [PMID: 27154325 PMCID: PMC6877884 DOI: 10.1016/j.aprim.2016.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 04/06/2016] [Indexed: 11/17/2022] Open
Affiliation(s)
- Consuelo Laudo Pardos
- Área de Farmacología, Facultad de Fisioterapia de Soria, Universidad de Valladolid, Soria, España.
| | - Víctor Puigdevall Gallego
- Unidad de Endocrinología, Servicio de Medicina Interna, Complejo Hospitalario de Soria, Soria, España
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22
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Varvaki Rados D, Catani Pinto L, Reck Remonti L, Bauermann Leitão C, Gross JL. The Association between Sulfonylurea Use and All-Cause and Cardiovascular Mortality: A Meta-Analysis with Trial Sequential Analysis of Randomized Clinical Trials. PLoS Med 2016; 13:e1001992. [PMID: 27071029 PMCID: PMC4829174 DOI: 10.1371/journal.pmed.1001992] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 03/01/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Sulfonylureas are an effective and inexpensive treatment for type 2 diabetes. There is conflicting data about the safety of these drugs regarding mortality and cardiovascular outcomes. The objective of the present study was to evaluate the safety of the sulfonylureas most frequently used and to use trial sequential analysis (TSA) to analyze whether the available sample was powered enough to support the results. METHODS AND FINDINGS Electronic databases were reviewed from 1946 (Embase) or 1966 (MEDLINE) up to 31 December 2014. Randomized clinical trials (RCTs) of at least 52 wk in duration evaluating second- or third-generation sulfonylureas in the treatment of adults with type 2 diabetes and reporting outcomes of interest were included. Primary outcomes were all-cause and cardiovascular mortality. Additionally, myocardial infarction and stroke events were evaluated. Data were summarized with Peto odds ratios (ORs), and the reliability of the results was evaluated with TSA. Forty-seven RCTs with 37,650 patients and 890 deaths in total were included. Sulfonylureas were not associated with all-cause (OR 1.12 [95% CI 0.96 to 1.30]) or cardiovascular mortality (OR 1.12 [95% CI 0.87 to 1.42]). Sulfonylureas were also not associated with increased risk of myocardial infarction (OR 0.92 [95% CI 0.76 to 1.12]) or stroke (OR 1.16 [95% CI 0.81 to 1.66]). TSA could discard an absolute difference of 0.5% between the treatments, which was considered the minimal clinically significant difference. The major limitation of this review was the inclusion of studies not designed to evaluate safety outcomes. CONCLUSIONS Sulfonylureas are not associated with increased risk for all-cause mortality, cardiovascular mortality, myocardial infarction, or stroke. Current evidence supports the safety of sulfonylureas; an absolute risk of 0.5% could be firmly discarded. REVIEW REGISTRATION PROSPERO CRD42014004330.
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Affiliation(s)
- Dimitris Varvaki Rados
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
- * E-mail:
| | - Lana Catani Pinto
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
| | - Luciana Reck Remonti
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
| | - Cristiane Bauermann Leitão
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
| | - Jorge Luiz Gross
- Division of Endocrinology, Hospital de Clínicas de Porto
Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre,
Brazil
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Higher Risk of Sulfonylurea-associated Hypoglycemic Symptoms in Women with Type 2 Diabetes Mellitus. Clin Drug Investig 2015; 35:593-600. [DOI: 10.1007/s40261-015-0314-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Cefalu WT, Boulton AJ, Tamborlane WV, Moses RG, LeRoith D, Greene EL, Hu FB, Bakris G, Wylie-Rosett J, Rosenstock J, Weinger K, Blonde L, de Groot M, Riddle MC, Henry R, Golden SH, Rich S, Reynolds L. Status of Diabetes Care: New Challenges, New Concepts, New Measures--Focusing on the Future! Diabetes Care 2015; 38:1177-80. [PMID: 26312261 PMCID: PMC5131862 DOI: 10.2337/dc15-0875] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- William T. Cefalu
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA
| | | | | | | | - Derek LeRoith
- Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Eddie L. Greene
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Frank B. Hu
- Departments of Nutrition and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - George Bakris
- ASH Comprehensive Hypertension Center, Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, The University of Chicago Medicine, Chicago, IL
| | - Judith Wylie-Rosett
- Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Julio Rosenstock
- Dallas Diabetes and Endocrine Center at Medical City, Dallas, TX
| | - Katie Weinger
- Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Lawrence Blonde
- Ochsner Diabetes Clinical Research Unit, Frank Riddick Diabetes Institute, Department of Endocrinology, Ochsner Medical Center, New Orleans, LA
| | - Mary de Groot
- Indiana University School of Medicine, Indianapolis, IN
| | - Matthew C. Riddle
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Portland, OR
| | | | - Sherita Hill Golden
- Division of Endocrinology and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephen Rich
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA
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Genuth S. Response to comment on Genuth. Should sulfonylureas remain an acceptable first-line add-on to metformin therapy in patients with type 2 diabetes? No, it's time to move on! Diabetes Care 2015;38:170-175. Diabetes Care 2015; 38:e95. [PMID: 25998309 DOI: 10.2337/dc15-0519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Saul Genuth
- Case Western Reserve University, Cleveland, OH
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Winkler G. [Sulfonylureas in today's blood glucose lowering therapy. New data on advantages and potential barriers of an "old" antidiabetic group]. Orv Hetil 2015; 156:511-5. [PMID: 25796278 DOI: 10.1556/oh.2015.30114] [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
Sulfonylurea compounds have been basic elements of antidiabetic treatment in type 2 diabetes for a long time. However, with the introduction of incretin type insulin secretagogues it is often arises, whether is still there a place for sulfonylureas in the today's therapy. To answer this question the author overviews general pharmaceutical characteristics of the sulfonylurea compounds as well as individual particularities of the second generation derivatives used at present in Hungary. The author details also the most important differences between incretin type drugs - first of all dipeptidyl peptidase-4 inhibitors - and sulfonylureas. On the basis of available data it can be concluded in accordance with the latest international guidelines, that sulfonylureas have still role in the blood glucose lowering therapy of type 2 diabetes, though they became somewhat pushed back among insulin secretagogue type drugs. If a sulfonylurea compound is the drug of choice, it is important to select the appropriate molecule (in case of normal renal function gliclazide or glimepiride). It is also important to re-educate the patient, as well as to apply the minimal dose providing the desired glycaemic effect.
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Affiliation(s)
- Gábor Winkler
- Fővárosi Szent János Kórház II. Belgyógyászat-Diabetológia Budapest Diós árok 1-3. 1125 Miskolci Egyetem, Egészségügyi Kar Elméleti Egészségtudományi Intézet Miskolc
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