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Hidayat K, Zhou YY, Du HZ, Qin LQ, Shi BM, Li ZN. A systematic review and meta-analysis of observational studies of the association between the use of incretin-based therapies and the risk of pancreatic cancer. Pharmacoepidemiol Drug Saf 2023; 32:107-125. [PMID: 36224724 DOI: 10.1002/pds.5550] [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: 10/15/2021] [Revised: 09/25/2022] [Accepted: 10/04/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Some early reports in the medical literature have raised concern about a possible increased risk of pancreatic cancer associated with the use of two broad classes of incretin-based therapies, dipeptidyl peptidase-4 inhibitors, and glucagon-like peptide-1 receptor agonists. This possibility has been somewhat mitigated by the null findings meta-analyses of randomized controlled trials, but the usefulness of their findings was hampered by serious shortcomings of lack of power and representativeness. These shortcomings can typically be addressed by observational studies, but observational studies on the topic have yielded conflicting findings. A systematic review and meta-analysis of observational studies was performed to qualitatively and quantitatively appraise the totality of evidence on the association between the use of incretin-based therapies and the risk of pancreatic cancer in routine clinical practice. METHODS The PubMed, Web of Science, Embase, and Google Scholar databases were searched. The study quality was appraised using the ROBINS-I tool and based on the presence of pharmacoepidemiology biases. A random-effects model was used to estimate the summary relative risks with corresponding CIs. RESULTS A total of 14 studies were included. The qualitative assessment revealed that all studies had inadequate follow-up (≤5 years), 12 studies were suspected to suffer from time-lag bias (due to inappropriate choice of comparator group) to varying extent, five studies included prevalent users, five studies did not implement exposure lag period, five studies had a serious risk of bias due to confounding, and one study had a time-window bias. The quantitative assessment showed no indication of an increased risk when all studies were pooled together (RR 1.04, 95% CI 0.87, 1.24) and when the analysis was restricted to the studies with the least bias (RR 0.77, 95% CI 0.51, 1.17). However, the pooled RRs were more frequently higher in the studies with less rigorous design and analysis. Specifically, a tendency toward an increased risk was observed in the studies with (RR 1.34, 95% CI 1.04, 1.72) or possibly with (RR 1.10, 95% CI 0.89, 1.36) time-lag bias, in the studies that did not apply (RR 1.23, 95% CI 0.93, 1.63) or with potentially inadequate exposure lag period of 6 months (RR 1.13, 95% CI 0.66, 1.94), in the studies that inappropriate comparator group of a combination of unspecified (RR 1.49, 95% CI 1.25, 1.78) or non-insulin (RR 1.15, 95% CI 0.93, 1.42) antidiabetic drugs, and in the studies with serious risk of bias due to confounding (RR 1.18, 95% CI 0.56, 2.49). CONCLUSIONS In summary, the totality of evidence from observational studies does not support the claim that the use of incretin-based therapies is associated with an increased risk of pancreatic cancer in routine clinical practice. The increased risk of pancreatic cancer observed in observational studies reflects bias resulting from suboptimal methodological approaches, which need to be avoided by future studies.
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Affiliation(s)
- Khemayanto Hidayat
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Soochow University, Suzhou, China.,Department of Nutrition and Food Hygiene, School of Public Health, Soochow University, Suzhou, China
| | - Ying-Yi Zhou
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hong-Zhen Du
- Department of Nutrition, The First Hospital of Hebei Medical University, Hebei Province Key Laboratory of Nutrition, Shijiazhuang, China
| | - Li-Qiang Qin
- Department of Nutrition and Food Hygiene, School of Public Health, Soochow University, Suzhou, China
| | - Bi-Min Shi
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zeng-Ning Li
- Department of Nutrition, The First Hospital of Hebei Medical University, Hebei Province Key Laboratory of Nutrition, Shijiazhuang, China
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Roberto G, Girardi A, Barone-Adesi F, Pecere A, Ientile V, Bartolini C, Da Cas R, Spila-Alegiani S, Ferrajolo C, Francesconi P, Trifirò G, Poluzzi E, Baccetti F, Gini R. Time to Treatment Intensification in Patients Receiving DPP4 Inhibitors Versus Sulfonylureas as the First Add-On to Metformin Monotherapy: A Retrospective Cohort Study. Front Pharmacol 2022; 13:871052. [PMID: 35707398 PMCID: PMC9189773 DOI: 10.3389/fphar.2022.871052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background: To verify whether, in patients on metformin (MET) monotherapy for type 2 diabetes (T2D), the add-on of a dipeptidyl peptidase inhibitor (DPP4i) compared to a sulfonylurea (SU) can delay the time to the subsequent treatment intensification (TI). Methods: Population-based administrative data banks from four Italian geographic areas were used. Patients aged ≥18 years on MET monotherapy receiving first DPP4i or SU dispensing between 2008 and 2015 (cohort entry) were followed up to the occurrence of TI (insulin dispensing or add-on of a third non-insulin hypoglicemic >180 days after cohort entry), treatment discontinuation, switch, cancer, death, TI occurrence within, end of data availability, end of study period (31 December 2016), whichever came first. Patients on MET + DPP4i were matched 1:1 with those on MET + SU by sex, age, year of cohort entry, and data bank. Hazard Ratio (HR) and 95% confidence intervals (95%CI) were estimated using multivariable Cox regression model including matching variables and potential confounders measured at baseline. Different sensitivity analyses were performed: i) matching at 180 days after cohort entry, ii) intent to treat (ITT) analysis, iii) matching by duration of MET monotherapy, iv) matching by propensity score. Results: The matched study cohort included 10,600 patients. Overall, 763 TI were observed (4.5/100 person-years; mean follow-up = 1.6 years). The primary analysis showed no difference in time to TI between the two groups (HR = 1.02; 95% CI = 0.88–1.19). Sensitivity analyses confirmed this result, except from the ITT analysis (HR = 1.27; 1.13–1.43). Conclusion: The use of a DPP4i rather than a SU as add-on to MET monotherapy was not associated with a delay in treatment intensification.
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Affiliation(s)
- Giuseppe Roberto
- Osservatorio di Epidemiologia, Agenzia Regionale di Sanità Della Toscana, Firenze, Italy
- *Correspondence: Giuseppe Roberto,
| | - Anna Girardi
- Osservatorio di Epidemiologia, Agenzia Regionale di Sanità Della Toscana, Firenze, Italy
| | - Francesco Barone-Adesi
- Dipartimento di Medicina Traslazionale, Università Del Piemonte Orientale, Novara, Italy
| | - Alessandro Pecere
- Dipartimento di Medicina Traslazionale, Università Del Piemonte Orientale, Novara, Italy
| | - Valentina Ientile
- Dipartimento di Scienze Biomediche, Odontoiatriche e Delle Immagini Morfologiche e Funzionali, Università Degli Studi di Messina, Messina, Italy
| | - Claudia Bartolini
- Osservatorio di Epidemiologia, Agenzia Regionale di Sanità Della Toscana, Firenze, Italy
| | - Roberto Da Cas
- Centro Nazionale per la Ricerca e la Valutazione Preclinica e Clinica Dei Farmaci, Istituto Superiore di Sanità, Roma, Italy
| | - Stefania Spila-Alegiani
- Centro Nazionale per la Ricerca e la Valutazione Preclinica e Clinica Dei Farmaci, Istituto Superiore di Sanità, Roma, Italy
| | - Carmen Ferrajolo
- Dipartimento di Medicina Sperimentale, Università Degli Studi Della Campania “L. Vanvitelli” e Centro Regionale di Farmacovigilanza, Regione Campania, Napoli, Italy
| | - Paolo Francesconi
- Osservatorio di Epidemiologia, Agenzia Regionale di Sanità Della Toscana, Firenze, Italy
| | - Gianluca Trifirò
- Dipartimento di Scienze Biomediche, Odontoiatriche e Delle Immagini Morfologiche e Funzionali, Università Degli Studi di Messina, Messina, Italy
| | - Elisabetta Poluzzi
- Unità di Farmacologia, Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Fabio Baccetti
- Unità Operativa di Diabetologia Massa-Carrara, USL Toscana Nordovest, Massa, Italy
| | - Rosa Gini
- Osservatorio di Epidemiologia, Agenzia Regionale di Sanità Della Toscana, Firenze, Italy
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Kawakita E, Koya D, Kanasaki K. CD26/DPP-4: Type 2 Diabetes Drug Target with Potential Influence on Cancer Biology. Cancers (Basel) 2021; 13:cancers13092191. [PMID: 34063285 PMCID: PMC8124456 DOI: 10.3390/cancers13092191] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Dipeptidyl peptidase (DPP)-4 inhibitor is widely used for type 2 diabetes. Although DPP-4/CD26 has been recognized as both a suppressor and inducer in tumor biology due to its various functions, how DPP-4 inhibitor affects cancer progression in diabetic patients is still unknown. The aim of this review is to summarize one unfavorable aspect of DPP-4 inhibitor in cancer-bearing diabetic patients. Abstract DPP-4/CD26, a membrane-bound glycoprotein, is ubiquitously expressed and has diverse biological functions. Because of its enzymatic action, such as the degradation of incretin hormones, DPP-4/CD26 is recognized as the significant therapeutic target for type 2 diabetes (T2DM); DPP-4 inhibitors have been used as an anti-diabetic agent for a decade. The safety profile of DPP-4 inhibitors for a cardiovascular event in T2DM patients has been widely analyzed; however, a clear association between DPP-4 inhibitors and tumor biology is not yet established. Previous preclinical studies reported that DPP-4 suppression would impact tumor progression processes. With regard to this finding, we have shown that the DPP-4 inhibitor induces breast cancer metastasis and chemoresistance via an increase in its substrate C-X-C motif chemokine 12, and the consequent induction of epithelial-mesenchymal transition in the tumor. DPP-4/CD26 plays diverse pivotal roles beyond blood glucose control; thus, DPP-4 inhibitors can potentially impact cancer-bearing T2DM patients either favorably or unfavorably. In this review, we primarily focus on the possible undesirable effect of DPP-4 inhibition on tumor biology. Clinicians should note that the safety of DPP-4 inhibitors for diabetic patients with an existing cancer is an unresolved issue, and further mechanistic analysis is essential in this field.
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Affiliation(s)
- Emi Kawakita
- Internal Medicine 1, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo 693-8501, Japan;
| | - Daisuke Koya
- Department of Diabetology & Endocrinology, Kanazawa Medical University, Uchinada 920-0293, Japan;
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada 920-0293, Japan
| | - Keizo Kanasaki
- Internal Medicine 1, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo 693-8501, Japan;
- Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada 920-0293, Japan
- Correspondence: ; Tel.: +81-853-20-2183
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Mosquera JE, Torres N, Restrepo J, Ruz-Pau C, Suryanarayanan S. LINAGLIPTIN-INDUCED PANCREATITIS. AACE Clin Case Rep 2020; 6:e37-e39. [PMID: 33163625 DOI: 10.4158/accr-2019-0307] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 10/05/2019] [Indexed: 12/13/2022] Open
Abstract
Objective To report a case of linagliptin-induced acute pancreatitis and remind clinicians about risks with incretin-based drugs. Patients at risk for pancreatitis should be switched to another type of hypoglycemic treatment. Methods We present the case of a 74-year-old Latina who presented to the emergency department with sudden onset of epigastric pain radiating to her back. Medical history, physical exam, laboratory tests, and medical images were compatible with acute pancreatitis. Upon further investigation, common causes for her pathology were excluded. Ten weeks prior to presentation she had changed her medications for diabetes mellitus type 2 to linagliptin. Results Using the Naranjo algorithm of adverse drug reactions, we concluded that linagliptin was the most likely culprit. Conclusion Incretin-based drugs, including dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists, have been shown to be relatively safe for the management of type 2 diabetes mellitus. Since their introduction to the market, conflicting data regarding pancreatic side effects have been published, including a small risk of developing acute pancreatitis with dipeptidyl peptidase-4 inhibitors like sitagliptin and saxagliptin. To date there has been only 1 case report associating linagliptin with acute pancreatitis in the English medical literature. Ours is the first case report in the United States associating linagliptin with acute pancreatitis. It is worth warning both patients and prescribers about this serious adverse effect, as it might affect the choice of antiglycemic agent.
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Montvida O, Green JB, Atherton J, Paul SK. Treatment with incretins does not increase the risk of pancreatic diseases compared to older anti-hyperglycaemic drugs, when added to metformin: real world evidence in people with Type 2 diabetes. Diabet Med 2019; 36:491-498. [PMID: 30306620 DOI: 10.1111/dme.13835] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2018] [Indexed: 12/23/2022]
Abstract
AIMS In people with metformin-treated diabetes, to evaluate the risk of acute pancreatitis, pancreatic cancer and other diseases of the pancreas post second-line anti-hyperglycaemic agent initiation. METHODS People with Type 2 diabetes diagnosed after 2004 who received metformin plus a dipeptidyl peptidase-4 inhibitor (DPP-4i, n = 50 095), glucagon-like peptide-1 receptor agonist (GLP-1RA, n = 12 654), sulfonylurea (n = 110 747), thiazolidinedione (n = 17 597) or insulin (n = 34 805) for at least 3 months were identified in the US Centricity Electronic Medical Records. Time to developing acute pancreatitis, other diseases of the pancreas and pancreatic cancer was estimated, balancing and adjusting anti-hyperglycaemic drug groups for appropriate confounders. RESULTS In the DPP-4i group, the adjusted mean time to acute pancreatitis was 2.63 [95% confidence intervals (CI) 2.38, 2.88] years; time to pancreatic cancer was 2.70 (2.19, 3.21) years; and time to other diseases of the pancreas was 2.73 (2.33, 3.12) years. Compared with DPP-4i, the insulin group developed acute pancreatitis 0.48 years (P < 0.01) earlier and the GLP-1RA group developed pancreatic cancer 3 years later (P < 0.01). However, with the constraint of no event within 6 months of insulin initiation, the risk of acute pancreatitis in the insulin group was insignificant. No other significant differences were observed between groups. CONCLUSIONS No significant differences in the risk of developing pancreatic diseases in those treated with various anti-hyperglycaemic drug classes were found.
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Affiliation(s)
- O Montvida
- Statistics Unit, QIMR Berghofer Medical Research Institute
- School of Biomedical Sciences, Queensland University of Technology, Brisbane, Australia
| | - J B Green
- Division of Endocrinology and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - J Atherton
- Cardiology Department, Royal Brisbane and Women's Hospital and University of Queensland School of Medicine, Brisbane
| | - S K Paul
- Statistics Unit, QIMR Berghofer Medical Research Institute
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, Australia
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Sharma D, Verma S, Vaidya S, Kalia K, Tiwari V. Recent updates on GLP-1 agonists: Current advancements & challenges. Biomed Pharmacother 2018; 108:952-962. [PMID: 30372907 DOI: 10.1016/j.biopha.2018.08.088] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/04/2018] [Accepted: 08/15/2018] [Indexed: 12/16/2022] Open
Abstract
Glucagon-like peptide (GLP)-1 is an incretin hormone exhibiting several pharmacological actions such as neuroprotection, increased cognitive function, cardio-protection, decreased hypertension, suppression of acid secretion, increase in lyposis, and protection from inflammation. The most potent actions are glucose-dependent insulinotropic and glucagonostatic actions, stimulation of β-cell proliferation, enhanced insulin secretion and reduced weight gain in patients with type-2 diabetes pertaining to blood glucose control. Despite all these actions, its short half-life (around 2∼min) and degradation by a dipeptidyl peptidase-4 enzyme (DPP-4) limits the therapeutic utility of GLP1. In this review, we have discussed DPP IV-resistant analogs of GLP-1 currently present in clinical trials such as Exenatide, Liraglutide, Semaglutide, Efpeglenatide, Exenatide ER, Ittca 650 (Intarcia), Dulaglutide, Albiglutide, and Lixisenatide. Moreover, we have also discussed in detail the pharmacology, signaling mechanisms, and pharmacokinetic properties (Cmax, Tmax, T1/2, Vd, and Bioavailability) of DPP IV-resistant analogs of (GLP-1). Interestingly, GLP-1 agonist drugs have shown better potential to treat type-2 diabetes mellitus (T2DM) as compared to currently used drugs in clinics without causing the side effects of hypoglycemia and weight gain.
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Affiliation(s)
- Dilip Sharma
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Gandhinagar 382355, Gujarat, India
| | - Suril Verma
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Gandhinagar 382355, Gujarat, India
| | - Shivani Vaidya
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Gandhinagar 382355, Gujarat, India
| | - Kiran Kalia
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Gandhinagar 382355, Gujarat, India.
| | - Vinod Tiwari
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Gandhinagar 382355, Gujarat, India.
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Hong JL, Buse JB, Jonsson Funk M, Pate V, Stürmer T. The Risk of Acute Pancreatitis After Initiation of Dipeptidyl Peptidase 4 Inhibitors: Testing a Hypothesis of Subgroup Differences in Older U.S. Adults. Diabetes Care 2018; 41:1196-1203. [PMID: 29618573 PMCID: PMC5961396 DOI: 10.2337/dc17-2212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 03/12/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine whether dipeptidyl peptidase 4 inhibitors (DPP-4I) increase acute pancreatitis risk in older patients and whether the association varies by age, sex, and history of cardiovascular disease (CVD). RESEARCH DESIGN AND METHODS We conducted a cohort study of DPP-4I initiators versus thiazolidinedione (TZD) or sulfonylurea initiators using U.S. Medicare beneficiaries, 2007-2014. Eligible initiators were aged 66 years or older without history of pancreatic disease or alcohol-related diseases. Patients were followed up for hospitalization due to acute pancreatitis and censored at 90 days after treatment changes. Weighted Cox models were used to estimate the hazard ratio (HR) for acute pancreatitis. Analyses were performed overall as well as within subgroups defined by age, sex, and CVD history. RESULTS We found no increased risk of acute pancreatitis comparing 49,374 DPP-4I initiators to 132,223 sulfonylurea initiators (weighted HR 1.01; 95% CI 0.83-1.24) and comparing 57,301 DPP-4I initiators to 32,612 TZD initiators (weighted HR 1.11; 95% CI 0.76-1.62). Age and sex did not modify the association. Among patients with CVD, acute pancreatitis incidence was elevated in initiators of DPP-4I and sulfonylurea (2.3 and 2.4 per 1,000 person-years, respectively) but not in TZD initiators (1.5). Among patients with CVD, higher risk of acute pancreatitis was observed with DPP-4I compared with TZD (weighted HR 1.84; 95% CI 1.02-3.35) but not compared with sulfonylurea. CONCLUSIONS Our study provides evidence that DPP-4I is not associated with an increased risk of acute pancreatitis in older adults overall. The positive association observed in patients with CVD could be due to chance or bias but merits further investigation.
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Affiliation(s)
- Jin-Liern Hong
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - John B Buse
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michele Jonsson Funk
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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8
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Optimization of peptide-based polyagonists for treatment of diabetes and obesity. Bioorg Med Chem 2018; 26:2873-2881. [DOI: 10.1016/j.bmc.2017.10.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 10/31/2017] [Indexed: 12/28/2022]
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9
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Murphy CF, le Roux CW. Can we exonerate GLP-1 receptor agonists from blame for adverse pancreatic events? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:186. [PMID: 29951508 DOI: 10.21037/atm.2018.03.06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Conor F Murphy
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin, Ireland
| | - Carel W le Roux
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin, Ireland.,Gastrosurgical laboratory, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Mazer-Amirshahi M, Pourmand A. Advances in Diabetes Pharmacotherapy: An Update for the Emergency Provider. J Emerg Med 2018; 54:73-80. [DOI: 10.1016/j.jemermed.2017.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/16/2017] [Accepted: 08/08/2017] [Indexed: 10/18/2022]
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11
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Chen FF, Wang JT, Zhang LX, Xing SF, Wang YX, Wang K, Deng SL, Zhang JQ, Tang L, Wu HS. Oleanolic acid derivative DKS26 exerts antidiabetic and hepatoprotective effects in diabetic mice and promotes glucagon-like peptide-1 secretion and expression in intestinal cells. Br J Pharmacol 2017. [PMID: 28627773 DOI: 10.1111/bph.13921] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Glucagon-like peptide-1 (GLP-1) is an important target for diabetes therapy based on its key role in maintaining glucose and lipid homeostasis. This study was designed to investigate antidiabetic and hepatoprotective effects of a novel oleanolic acid derivative DKS26 in diabetic mice and elucidate its underlying GLP-1 related antidiabetic mechanisms in vitro and in vivo. EXPERIMENTAL APPROACH The therapeutic effects of DKS26 were investigated in streptozotocin (STZ)-induced and db/db diabetic mouse models. Levels of plasma glucose, glycosylated serum protein (GSP), lipid profiles, insulin, alanine aminotransferase (ALT) and aspartate aminotransferase (AST), oral glucose tolerance (OGT), pancreatic islets and hepatic histopathological morphology, liver lipid levels and expression of pro-inflammatory cytokines were assessed. Intestinal NCI-H716 cells and diabetic models were used to further validate its potential GLP-1-related antidiabetic mechanisms. KEY RESULTS DKS26 treatment (100 mg·kg-1 ·day-1 ) decreased plasma levels of glucose, GSP, ALT and AST; ameliorated OGT and plasma lipid profiles; augmented plasma insulin levels; alleviated islets and hepatic pathological morphology; and reduced liver lipid accumulation, inflammation and necrosis in vivo. Furthermore, DKS26 enhanced GLP-1 release and expression, accompanied by elevated levels of cAMP and phosphorylated PKA in vitro and in vivo. CONCLUSION AND IMPLICATIONS DKS26 exerted hypoglycaemic, hypolipidaemic and islets protective effects, which were associated with an enhanced release and expression of GLP-1 mediated by the activation of the cAMP/PKA signalling pathway, and alleviated hepatic damage by reducing liver lipid levels and inflammation. These findings firmly identified DKS26 as a new viable therapeutic option for diabetes control.
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Affiliation(s)
- Fei-Fei Chen
- Experiment Education Center for Pharmaceutical Sciences, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China.,Institute of Pharmacology & Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Jian-Ta Wang
- College of Pharmacy, Guizhou Medical University, Guiyang, China
| | - Li-Xia Zhang
- Experiment Education Center for Pharmaceutical Sciences, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Shu-Fang Xing
- Experiment Education Center for Pharmaceutical Sciences, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Yun-Xia Wang
- Experiment Education Center for Pharmaceutical Sciences, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Kai Wang
- Experiment Education Center for Pharmaceutical Sciences, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Shu-Li Deng
- Department of Conservative Dentistry, Affiliated Hospital of Stomatology, Zhejiang University, Hangzhou, China
| | - Ji-Quan Zhang
- College of Pharmacy, Guizhou Medical University, Guiyang, China
| | - Lei Tang
- College of Pharmacy, Guizhou Medical University, Guiyang, China
| | - Hao-Shu Wu
- Experiment Education Center for Pharmaceutical Sciences, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China.,Institute of Pharmacology & Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
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12
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Leporini C, Piro R, Ursini F, Maida F, Palleria C, Arturi F, Pavia M, De Sarro G, Russo E. Monitoring safety and use of old and new treatment options for type 2 diabetic patients: a two-year (2013-2016) analysis. Expert Opin Drug Saf 2017; 15:17-34. [PMID: 27718744 DOI: 10.1080/14740338.2016.1246531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To compare patients' and physicians' perceptions regarding effectiveness and tolerability of non-insulin hypoglycemic drugs in a cohort of type 2 diabetic patients; to verify whether a possible tridimensional link between effectiveness, tolerability, and adherence affects long-term therapeutic outcomes. METHODS A two-year observational study was performed in 1389 Type 2 diabetic patients by involving general practitioner clinics and Diabetes Centers. A decimal scale and the Morisky questionnaire were used, respectively, to assess effectiveness and tolerability perceptions, and medication adherence. RESULTS Physicians perceived therapy as more efficacious compared to their patients: perceived effectiveness was steady for physicians during the study whereas patients' perception not significantly decreased (mean score from >8 to 7.84 ± 1.69). Physicians assigned higher tolerability scores compared to patients but only at the beginning of the study; interestingly, physicians' tolerability perception was poorer than patients' perception at last follow-up (mean score = 7.57 ± 1.40 vs. 7.88 ± 1.84). Favorable (score >7) patients' perceptions about treatment effectiveness and tolerability were associated with higher adherence. Patients showed medium adherence across the study. CONCLUSIONS A mutual relationship between clinical effectiveness, adverse drug reactions, and adherence has been established, significantly impacting the clinical management of diabetic patients. A careful monitoring of this link by clinicians appears therefore necessary.
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Affiliation(s)
- Christian Leporini
- a School of Medicine and Surgery, Department of Health Sciences, Clinical Pharmacology and Pharmacovigilance Unit , 'Magna Graecia' University of Catanzaro , Catanzaro , Italy
| | - Rosanna Piro
- b 'S Francesco di Paola' Hospital , Diabetology and Metabolic Diseases Unit , Paola , Italy
| | - Francesco Ursini
- a School of Medicine and Surgery, Department of Health Sciences, Clinical Pharmacology and Pharmacovigilance Unit , 'Magna Graecia' University of Catanzaro , Catanzaro , Italy
| | - Francesca Maida
- a School of Medicine and Surgery, Department of Health Sciences, Clinical Pharmacology and Pharmacovigilance Unit , 'Magna Graecia' University of Catanzaro , Catanzaro , Italy
| | - Caterina Palleria
- a School of Medicine and Surgery, Department of Health Sciences, Clinical Pharmacology and Pharmacovigilance Unit , 'Magna Graecia' University of Catanzaro , Catanzaro , Italy
| | - Franco Arturi
- c Department of Medical and Surgical Sciences, Internal Medicine Unit of 'Mater Domini' University Hospital , 'Magna Graecia' University of Catanzaro , Catanzaro , Italy
| | - Maria Pavia
- d Department of Health Sciences, Medical School , University of Catanzaro 'Magna Græcia', Campus of Germaneto , Catanzaro , Italy
| | - Giovambattista De Sarro
- a School of Medicine and Surgery, Department of Health Sciences, Clinical Pharmacology and Pharmacovigilance Unit , 'Magna Graecia' University of Catanzaro , Catanzaro , Italy
| | - Emilio Russo
- a School of Medicine and Surgery, Department of Health Sciences, Clinical Pharmacology and Pharmacovigilance Unit , 'Magna Graecia' University of Catanzaro , Catanzaro , Italy
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Knapen LM, de Jong RGPJ, Driessen JHM, Keulemans YC, van Erp NP, De Bruin ML, Leufkens HGM, Croes S, de Vries F. Use of incretin agents and risk of acute and chronic pancreatitis: A population-based cohort study. Diabetes Obes Metab 2017; 19:401-411. [PMID: 27883260 DOI: 10.1111/dom.12833] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/09/2016] [Accepted: 11/20/2016] [Indexed: 12/16/2022]
Abstract
AIM To determine the association between the use of incretin agents (dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists) for the treatment of type 2 diabetes mellitus (T2DM) and the risk of any, acute and chronic pancreatitis. RESEARCH DESIGN AND METHODS A population-based cohort study was conducted using data from the UK Clinical Practice Research Datalink (CPRD 2007-2012). A total of 182 428 adult patients with ≥1 non-insulin antidiabetic drug (NIAD) prescription were matched to control subjects without diabetes. Cox regression was used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of pancreatitis in incretin-users (N = 28 370) compared with controls and with other NIAD users. Adjustments were made for lifestyle, disease and drug history. In a sensitivity analysis, a new-user design was used. RESULTS Current incretin users had a 1.5-fold increased risk of any pancreatitis compared with NIAD users (adjusted HR 1.47, 95% CI 1.06-2.04). In incident current incretin users the risk of any and acute pancreatitis was increased 2.1- and 2.0-fold compared with NIAD users (adjusted HR 2.12, 95% CI 1.31-3.43 and adjusted HR 1.96, 95% CI 1.13-3.41), whereas there was no increased risk found for chronic pancreatitis. CONCLUSIONS Incretin use was associated with an increased risk of any pancreatitis. Moreover, risk of any and acute pancreatitis was higher when applying a new-user design. We were not able to detect an association with chronic pancreatitis, but the number in this subgroup was small.
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Affiliation(s)
- Lotte M Knapen
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- CAPHRI Care and Public Health Research Institute, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Roy G P J de Jong
- Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - Johanna H M Driessen
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- CAPHRI Care and Public Health Research Institute, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - Yolande C Keulemans
- Department of Gastroenterology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Nielka P van Erp
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marie L De Bruin
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - Hubert G M Leufkens
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - Sander Croes
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- CAPHRI Care and Public Health Research Institute, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Frank de Vries
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- CAPHRI Care and Public Health Research Institute, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
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Emoto M, Oura T, Matsui A, Kazama H, Iwamoto N. Pancreatic safety in Japanese patients with type 2 diabetes treated with once weekly dulaglutide 0.75 mg up to 52 weeks in phase 3 clinical trials. Endocr J 2017; 64:191-206. [PMID: 27853058 DOI: 10.1507/endocrj.ej16-0365] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The effects of incretin therapies on pancreatic safety are currently being evaluated. In 3 phase 3 clinical studies of once weekly dulaglutide 0.75 mg (dulaglutide) in Japanese patients with type 2 diabetes (T2D), symptoms suggestive of acute pancreatitis as well as pancreatic enzymes were assessed and the risk of acute pancreatitis was evaluated. Patients who met any of the predefined criteria (clinical signs/symptoms of acute pancreatitis, confirmed amylase or lipase level ≥3 times the upper limit of normal [ULN], abdominal imaging of the pancreas) were adjudicated for acute pancreatitis by a blinded external committee. A total of 43 events in 40 patients (dulaglutide, 35/917 patients; liraglutide, 2/137 patients; insulin glargine, 2/180 patients; and placebo, 2/70 patients) were adjudicated (1 patient had events adjudicated during both placebo and dulaglutide treatment); 2 patients treated with dulaglutide had acute pancreatitis confirmed (2/917 [0.2%]; 2.651 patients/1,000 patient-years). One of these patients was diagnosed by the investigator with acute pancreatitis related to dulaglutide, but there was no typical abdominal pain. The event in the other patient occurred following an endoscopic ultrasound-guided fine needle aspiration. Transient increases in lipase ≥3×ULN were observed in 2% of patients in both the dulaglutide and liraglutide groups; the incidence in dulaglutide-treated patients was not significantly different from the incidences in liraglutide, placebo-, or insulin glargine-treated patients. Results of systematic assessments of pancreatic safety in 3 phase 3 studies for up to 52 weeks do not suggest an increased risk of acute pancreatitis in Japanese patients treated with dulaglutide.
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Affiliation(s)
- Masanori Emoto
- Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka 545-8585, Japan
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Affiliation(s)
- J Hans DeVries
- Department of Endocrinology, Academic Medical Center at the University of Amsterdam, Amsterdam, the Netherlands
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Klil-Drori AJ, Azoulay L, Pollak MN. Cancer, obesity, diabetes, and antidiabetic drugs: is the fog clearing? Nat Rev Clin Oncol 2016; 14:85-99. [DOI: 10.1038/nrclinonc.2016.120] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Zietek T, Rath E. Inflammation Meets Metabolic Disease: Gut Feeling Mediated by GLP-1. Front Immunol 2016; 7:154. [PMID: 27148273 PMCID: PMC4840214 DOI: 10.3389/fimmu.2016.00154] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 04/08/2016] [Indexed: 12/14/2022] Open
Abstract
Chronic diseases, such as obesity and diabetes, cardiovascular, and inflammatory bowel diseases (IBD) share common features in their pathology. Metabolic disorders exhibit strong inflammatory underpinnings and vice versa, inflammation is associated with metabolic alterations. Next to cytokines and cellular stress pathways, such as the unfolded protein response (UPR), alterations in the enteroendocrine system are intersections of various pathologies. Enteroendocrine cells (EEC) have been studied extensively for their ability to regulate gastrointestinal motility, secretion, and insulin release by release of peptide hormones. In particular, the L-cell-derived incretin hormone glucagon-like peptide 1 (GLP-1) has gained enormous attention due to its insulinotropic action and relevance in the treatment of type 2 diabetes (T2D). Yet, accumulating data indicate a critical role for EEC and in particular for GLP-1 in metabolic adaptation and in orchestrating immune responses beyond blood glucose control. EEC sense the lamina propria and luminal environment, including the microbiota via receptors and transporters. Subsequently, mediating signals by secreting hormones and cytokines, EEC can be considered as integrators of metabolic and inflammatory signaling. This review focuses on L cell and GLP-1 functions in the context of metabolic and inflammatory diseases. The effects of incretin-based therapies on metabolism and immune system are discussed and the interrelation and common features of metabolic and immune-mediated disorders are highlighted. Moreover, it presents data on the impact of inflammation, in particular of IBD on EEC and discusses the potential role of the microbiota as link between nutrients, metabolism, immunity, and disease.
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Affiliation(s)
- Tamara Zietek
- Department of Nutritional Physiology, Technische Universität München , Freising , Germany
| | - Eva Rath
- Chair of Nutrition and Immunology, Technische Universität München , Freising , Germany
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Azoulay L, Filion KB, Platt RW, Dahl M, Dormuth CR, Clemens KK, Durand M, Juurlink DN, Targownik LE, Turin TC, Paterson JM, Ernst P. Incretin based drugs and the risk of pancreatic cancer: international multicentre cohort study. BMJ 2016; 352:i581. [PMID: 26888382 PMCID: PMC4772785 DOI: 10.1136/bmj.i581] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine whether the use of incretin based drugs compared with sulfonylureas is associated with an increased risk of incident pancreatic cancer in people with type 2 diabetes. DESIGN Population based cohort. SETTING Large, international, multicentre study combining the health records from six participating sites in Canada, the United States, and the United Kingdom. PARTICIPANTS A cohort of 972,384 patients initiating antidiabetic drugs between 1 January 2007 and 30 June 2013, with follow-up until 30 June 2014. MAIN OUTCOME MEASURES Within each cohort we conducted nested case-control analyses, where incident cases of pancreatic cancer were matched with up to 20 controls on sex, age, cohort entry date, duration of treated diabetes, and duration of follow-up. Hazard ratios and 95% confidence intervals for incident pancreatic cancer were estimated, comparing use of incretin based drugs with use of sulfonylureas, with drug use lagged by one year for latency purposes. Secondary analyses assessed whether the risk varied by class (dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists) or by duration of use (cumulative duration of use and time since treatment initiation). Site specific hazard ratios were pooled using random effects models. RESULTS During 2,024,441 person years of follow-up (median follow-up ranging from 1.3 to 2.8 years; maximum 8 years), 1221 patients were newly diagnosed as having pancreatic cancer (incidence rate 0.60 per 1000 person years). Compared with sulfonylureas, incretin based drugs were not associated with an increased risk of pancreatic cancer (pooled adjusted hazard ratio 1.02, 95% confidence interval 0.84 to 1.23). Similarly, the risk did not vary by class and evidence of a duration-response relation was lacking. CONCLUSIONS In this large, population based study the use of incretin based drugs was not associated with an increased risk of pancreatic cancer compared with sulfonylureas. Although this potential adverse drug reaction will need to be monitored long term owing to the latency of the cancer, these findings provide some reassurance on the safety of incretin based drugs.
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Affiliation(s)
- Laurent Azoulay
- Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, Montreal, Quebec, H3T 1E2, Canada Department of Oncology, McGill University, Montreal, Canada
| | - Kristian B Filion
- Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, Montreal, Quebec, H3T 1E2, Canada Department of Medicine, McGill University, Montreal, Canada
| | - Robert W Platt
- Departments of Pediatrics and of Epidemiology, Biostatistics, and Occupational Health, McGill University, and the Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Matthew Dahl
- Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada and Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Colin R Dormuth
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | | | - Madeleine Durand
- Department of Internal Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | | | - Laura E Targownik
- Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada and Department of Family Medicine, McMaster University, Hamilton, Canada Section of Gastroenterology, Division of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Tanvir C Turin
- Department of Family Medicine, University of Calgary, Calgary, Canada
| | - J Michael Paterson
- Institute for Clinical Evaluative Sciences, Toronto, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto
| | - Pierre Ernst
- Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, Montreal, Quebec, H3T 1E2, Canada Department of Medicine, McGill University, Montreal, Canada
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Finan B, Clemmensen C, Müller TD. Emerging opportunities for the treatment of metabolic diseases: Glucagon-like peptide-1 based multi-agonists. Mol Cell Endocrinol 2015; 418 Pt 1:42-54. [PMID: 26151488 DOI: 10.1016/j.mce.2015.07.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/24/2015] [Accepted: 07/02/2015] [Indexed: 12/18/2022]
Abstract
Obesity is a pathogenic gateway to the metabolic syndrome and the complications thereof, thus interventions aimed at preventing or reversing the metabolic derangements underlying obesity hold great therapeutic promise. However, the complexity of energy balance regulation, combined with the heterologous pathophysiology of human obesity, renders effective medicinal intervention very difficult. Indeed, the search for the silver bullet in anti-obesity medicines has been laden with drugs of underwhelming efficacy and unacceptable side effects. This can partly be the consequence that many of these drug interventions have been historically directed at single molecular targets. New multi-molecular combination therapies have shown promising clinical outcomes in terms of weight loss, yet multi-functional single molecules may offer even more advantages than adjunctive co-treatments. Single molecules with integrated activities derived from multiple hormones involved in the physiological control of metabolism have emerged as one of the more promising candidates for reversing obesity. The inclusion of glucagon-like peptide-1 (GLP-1) as one of the constituents is a unifying factor amongst the majority of these unimolecular multi-agonists. The scope of this review is to summarize the current preclinical and clinical landscape of GLP-1-based therapies, focusing on combinatorial therapies with a particular emphasis on single molecule compounds displaying multi-agonist properties.
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Affiliation(s)
- Brian Finan
- Institute for Diabetes and Obesity, Helmholtz Diabetes Center at Helmholtz Zentrum München, Neuherberg, Germany; Division of Metabolic Diseases, Department of Medicine, Technische Universität München, Munich, Germany.
| | - Christoffer Clemmensen
- Institute for Diabetes and Obesity, Helmholtz Diabetes Center at Helmholtz Zentrum München, Neuherberg, Germany; Division of Metabolic Diseases, Department of Medicine, Technische Universität München, Munich, Germany
| | - Timo D Müller
- Institute for Diabetes and Obesity, Helmholtz Diabetes Center at Helmholtz Zentrum München, Neuherberg, Germany; Division of Metabolic Diseases, Department of Medicine, Technische Universität München, Munich, Germany
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