Positioning SGLT2 Inhibitors/Incretin-Based Therapies in the Treatment Algorithm

Insights into SGLT2 inhibitor treatment of diabetic cardiomyopathy: focus on the mechanisms

Among the complications of diabetes, cardiovascular events and cardiac insufficiency are considered two of the most important causes of death. Experimental and clinical evidence supports the effectiveness of SGLT2i for improving cardiac dysfunction. SGLT2i treatment benefits metabolism, microcirculation, mitochondrial function, fibrosis, oxidative stress, endoplasmic reticulum stress, programmed cell death, autophagy, and the intestinal flora, which are involved in diabetic cardiomyopathy. This review summarizes the current knowledge of the mechanisms of SGLT2i for the treatment of diabetic cardiomyopathy.

The dual role of empagliflozin: Cardio renal protection in T2DM patients

Empagliflozin (Jardiance®) is an insulin independent antihyperglycemic agent used in treatment of T2D.The drug is a sodium glucose cotransporter-2 (SGLT2) inhibitor approved in USA and Europe and other countries of the world. As empagliflozin demonstrates cardioprotective and Reno protective properties its prime target are patients having CVD and CKD complicated by T2D.

This review sheds light on mechanism of action of the drug and with the help of clinical outcomes establishes the use of empagliflozin in T2D patients.

Although empagliflozin is a well-tolerated and easy to administer drug, it has some side effects and contraindications which are discussed in the article to help the reader weigh its beneficial effects against its adverse effect and understand its use in clinical medicine.

Effect of Ramadan fasting in patients with type 2 diabetes mellitus treated with sodium-glucose cotransporter 2 inhibitors: A systematic review and meta-analysis

AIMS/INTRODUCTION

Sodium-glucose cotransporter 2 inhibitors (SGLT-2i) improve glycemic control and weight, but might be associated with dehydration, hypotension and ketoacidosis, especially in patients with type 2 diabetes mellitus who fast during Ramadan. This meta-analysis evaluates the effects of Ramadan fasting on patients with type 2 diabetes mellitus treated with SGLT-2i.

MATERIALS AND METHODS

A literature search was carried out in PubMed, Embase and the Cochrane Library. Quality assessment was carried out using the ROBINS-I and Cochrane tools for risk of bias, and analyses were carried out using RevMan version 5.3.

RESULTS

A total of five studies were included in this meta-analysis. During Ramadan, there was a significant reduction in glycated hemoglobin (P < 0.00001) and diastolic blood pressure (P = 0.006), with a non-significant trend for a reduction in weight (P = 0.44) and systolic blood pressure (P = 0.67). The number and severity of hypoglycemic episodes was lower in patients with type 2 diabetes mellitus treated with SGLT-2i compared with sulfonylureas. There was no significant change in estimated glomerular filtration rate, β-hydroxybutyrate, bicarbonate or anion gap. However, we identified considerable heterogeneity among studies, and a lack of head-to-head studies with structured outcome reporting on the risks and benefits of SGLT-2i during Ramadan.

CONCLUSIONS

This systematic review and meta-analysis shows that patients with type 2 diabetes treated with SGLT2i's during Ramadan have an improvement in HbA1c, less hypoglycemia and no major adverse effects.

Trends in glycemic control in patients with insulin therapy compared with non-insulin or no drugs in type 2 diabetes in Japan: a long-term view of real-world treatment between 2002 and 2018 (JDDM 66)

INTRODUCTION

We investigated trends in the proportion of diabetes treatment and glycemic control, which may be altered by recent advances in insulin and non-insulin drugs, in Japanese patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A serial cross-sectional study was performed using a multicenter large-population database from the Japan Diabetes Clinical Data Management study group. Patients with type 2 diabetes who attended clinics belonging to the study group between 2002 and 2018 were included to examine trends in glycated hemoglobin A1c (HbA1c) by treatment group using multivariable non-linear regression model.

RESULTS

The proportion of patients with insulin only decreased from 15.0% to 3.6%, patients with insulin+non-insulin drugs increased from 8.1% to 15.1%, patients with non-insulin drugs increased from 50.8% to 67.0%, and those with no drugs decreased from 26.1% to 14.4% from 2002 to 2018, respectively. The HbA1c levels of each group, except for no drugs, continued to decrease until 2014 (unadjusted mean HbA1c (%) from 2002 to 2014: from 7.89 to 7.45 for insulin only, from 8.09 to 7.63 for insulin+non-insulin, and from 7.51 to 6.98 for non-insulin) and remained unchanged thereafter. Among insulin-treated patients, use of human insulin decreased, use of long-acting analog insulin increased, and concomitant use of non-insulin drugs increased (from 35.1% in 2002 to 80.9% in 2018), which included increased use of dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors, and glucagon-like peptide 1 receptor agonists, and the persistently high use of metformin.

CONCLUSIONS

During the past two decades, combined use of insulin and non-insulin drugs increased and glycemic control improved and leveled off after 2014 in Japanese patients with type 2 diabetes. Further studies of the trend in association with age and factors related to metabolic syndrome are necessary to investigate strategies aiming at personalized medicine in diabetes care.

Diabetes duration and types of diabetes treatment in data-driven clusters of patients with diabetes

BACKGROUND

This study aimed to cluster patients with diabetes and explore the association between duration of diabetes and diabetes treatment choices in each cluster.

METHODS

A Two-Step cluster analysis was performed on 1332 Chinese patients with diabetes based on six parameters (glutamate decarboxylase antibodies, age at disease onset, body mass index, glycosylated hemoglobin, homeostatic model assessment 2 to estimate β-cell function and insulin resistance). Associations between the duration of diabetes and diabetes treatment choices in each cluster of patients were analyzed using Kaplan-Meier survival curves and logistic regression models.

RESULTS

The following five replicable clusters were identified: severe autoimmune diabetes (SAID), severe insulin-deficient diabetes (SIDD), severe insulin-resistant diabetes (SIRD), mild obesity-related diabetes (MOD), and mild age-related diabetes (MARD). There were significant differences in blood pressure, blood lipids, and diabetes-related complications among the clusters (all P < 0.05). Early in the course of disease (≤5 years), compared with the other subgroups, the SIRD, MOD, and MARD populations were more likely to receive non-insulin hypoglycemic agents for glycemic control. Among the non-insulin hypoglycemic drug options, SIRD had higher rates of receiving metformin, alpha-glucosidase inhibitor (AGI), and glucagon-like peptide-1 drug; the MOD and MARD groups both received metformin, AGI and sodium-glucose cotransporter 2 inhibitor (SGLT-2i) drug ratio was higher. While the SAID and SIDD groups were more inclined to receive insulin therapy than the other subgroups, with SAID being more pronounced. With prolonged disease course (>5 years), only the MOD group was able to accept non-insulin hypoglycemic drugs to control the blood sugar levels, and most of them are still treated with metformin, AGI, and SGLT-2i drugs. While the other four groups required insulin therapy, with SIDD being the most pronounced.

CONCLUSIONS

Clustering of patients with diabetes with a data-driven approach yields consistent results. Each diabetes cluster has significantly different disease characteristics and risk of diabetes complications. With the development of the disease course, each cluster receives different hypoglycemic treatments.

Use of SGLT2 inhibitors during Ramadan: An expert panel statement

Fasting from dawn to sunset, during the holy month of Ramadan, constitutes one of the five main pillars in Islam and is observed by the majority of Muslims. Owing to important physiological changes, Ramadan fasting holds a crucial place in the context of diabetes management. Approximately one-fifth of the world's Muslim population resides in the Middle East and Africa (MEA) region. To discuss the challenges and management of diabetes during Ramadan fasting in the MEA region, a panel of 12 experts in the field of diabetes from across the MEA region attended two expert committee meetings held in Dubai. The key point of discussion was the safety and efficacy of the use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) during Ramadan, based on outcomes of the recent clinical trials with SGLT2i. This is the first consensus recommendation on the management of diabetes with SGLT2i across the MEA region during Ramadan. The document summarizes expert views and opinions on the current management of diabetes with SGLT2i during Ramadan and aims to enhance the current knowledge and understanding on the issue of diabetes management during Ramadan. This will aid the physicians of the MEA region with appropriate decision-making for their patients during Ramadan.

Evolving physicians' perceptions and practices regarding use of SGLT2 inhibitors for type 2 diabetes during Ramadan fasting

OBJECTIVES

We followed up the evolving perceptions and practices regarding use of SGLT-2 inhibitors in Ramadan.

METHODS

We compared results of the three survey in 2015, 2017, 2019.

RESULTS

Senior doctors represented 43.5-66.4% and endocrinologists accounted for 38.1-60.2%. There was a steady reduction in the proportions of respondents who did not know SGLT2-Is at all, who have just heard about the class and those who are quite familiar with the class but have not yet used any. Whereas the proportions of those using the SGLT2-Is class occasionally only was stable. However those who use the SGLT2-Is regularly increased from 11.0% to 45.6% and 62.6%. The respondents' who SGLT2-Is are safe and may be used in all fasting diabetic patients increased from 15.5%, 14.7% to 23.1%. Whereas the view that SGLT2-Is should not be used decreased progressively. Majority of respondents in the three surveys suggested that specific advice is given if they allow the use of SGLT2-Is during Ramadan. More respondents advise taking the medication with the first evening meal than before the last pre-dawn meal and advised to attend to their hydration status. One third of respondents would resume SGLT2-Is immediately after the end of Ramadan; 15% after 1-2 weeks, or prefer to wait till the next medical or educator's clinic visit and others would re-evaluate patients' management plan.

CONCLUSIONS

The medical professions' knowledge and perceptions regarding the use of SGLT2-Is during Ramadan fasting have evolved over the last few years due to increasing research and experience.

The efficacy and safety of combinations of SGLT2 inhibitors and GLP-1 receptor agonists in the treatment of type 2 diabetes or obese adults: a systematic review and meta-analysis

PURPOSE

To evaluate the efficacy and safety of combination therapy with sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists in the treatment of type 2 diabetes mellitus (T2DM) or obese adults.

METHODS

A meta-analysis was conducted of trials by searching in PubMed, Embase, CENTRAL, Web of Science, and Scopus.

RESULTS

A total of five randomized controlled trials (RCTs) and six nonrandomized controlled trials (NCTs) enrolled 1604 participants were identified for meta-analysis. Compared with control/placebo, the combination therapy group had significantly reduced fasting plasma glucose level and 2 h postprandial glucose by 1.28 mmol/L (95% confidence interval [CI]: -1.39, -1.16; p < 0.001) and 1.34 mmol/L (95% CI: -1.47, -1.21; p < 0.001); glycosylated hemoglobin (HbA1c) by 1.32% (95% CI: -1.43, -1.20; p < 0.001); body weight by 0.93 kg (95% CI: -1.04, -0.83; p < 0.001), and systolic blood pressure (SBP) by 1.05 mmHg (95% CI: -1.17, -0.93; p < 0.001). The incidence of genital mycotic infections and urinary infections did not significantly differ from those in the control group, with relative risks (RRs) of 1.67 (95% CI: 0.85, 3.27; p = 0.651) and 1.25 (95% CI: 0.73, 2.15; p = 0.905), respectively. A decreased incidence of cardiovascular events was seen in the combination therapy group (RR = 0.19; 95% CI: 0.04, 0.96; p = 0.403), while an incidence of hypoglycemia was reported (RR = 2.22; 95% CI: 1.20, 4.10; p = 0.71).

CONCLUSIONS

SGLT2 inhibitors and GLP-1 agonists combination treatment improved glycemic control, reduced body weight, and decreased SBP without an increase in total adverse events or genital and urinary infections in patients with T2DM or obesity.

The Effect of Glucagon-Like Peptide-1 Receptor Agonists and Sodium-Glucose Cotransporter-2 Inhibitors in Patients Prescribed Regular U-500 Insulin

Background: Only 2 small studies have examined the use of glucagon-like peptide-1 (GLP-1) receptor agonists with U-500 insulin, with mixed results. Moreover, there are no studies to our knowledge that have investigated use of sodium-glucose cotransporter-2 (SGLT-2) inhibitors with U-500 insulin therapy. Objective: This research was designed to determine the effectiveness of GLP-1 agonists and SGLT-2 inhibitors in patients already taking U-500 insulin. Methods: A retrospective chart review was conducted on patients using U-500 insulin to which a GLP-1 agonist or SGLT-2 inhibitor was added as their treatment protocol. The primary outcome measure was change in glycosylated hemoglobin (A1C) after 3 to 6 months on the additional therapy. Secondary outcomes included A1C change at 12 months, changes in total daily dose (TDD) of U-500 insulin, body mass index (BMI) and body weight from baseline, and episodes of hypoglycemia. Results: A total of 17 patients were included in the review. The combination of a GLP-1 agonist and/or SGLT-2 inhibitor with U-500 insulin resulted in significant reductions in A1C (0.84%, P = 0.004) and TDD of U-500 insulin (33.5 units, P = 0.031) at the 3- to 6-month interval. Furthermore, statistically significant decreases in mean BMI and body weight were observed 12 months postbaseline. Hypoglycemia occurred in the majority of patients (64.7%). Conclusion and Relevance: This is the first study to examine SGLT-2 inhibitors in combination with U-500 insulin therapy. Clinically, the addition of a GLP-1 agonist and/or SGLT-2 inhibitor can improve A1C and decrease TDD, BMI, and body weight.

Treatment of Diabetes in Older Adults: An Endocrine Society* Clinical Practice Guideline

OBJECTIVE

The objective is to formulate clinical practice guidelines for the treatment of diabetes in older adults.

CONCLUSIONS

Diabetes, particularly type 2, is becoming more prevalent in the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation. Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes complications. Each section in this guideline covers all aspects of the etiology and available evidence, primarily from controlled trials, on therapeutic options and outcomes in this population. The goal is to give guidance to practicing health care providers that will benefit patients with diabetes (both type 1 and type 2), paying particular attention to avoiding unnecessary and/or harmful adverse effects.

Evidence-Based Consensus on Positioning of SGLT2i in Type 2 Diabetes Mellitus in Indians

The current diabetes management strategies not only aim at controlling glycaemic parameters but also necessitate continuous medical care along with multifactorial risk reduction through a comprehensive management concept. The sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a group of evolving antidiabetic agents that have the potential to play a pivotal role in the comprehensive management of patients with diabetes due to their diverse beneficial effects. SGLT2i provide moderate glycaemic control, considerable body weight and blood pressure reduction, and thus have the ability to lower the risk of macrovascular and microvascular complications. Some of the unique characteristics associated with SGLT2i, such as reduction in body weight (more visceral fat mass loss than subcutaneous fat loss), reduction in insulin resistance and improvement in β-cell function, as measured by homeostatic model assessment-β (HOMA-β) could be potentially beneficial and help in overcoming some of the challenges faced by Indian patients with diabetes. In addition, a patient-centric approach with individualised treatment during SGLT2i therapy is inevitable in order to reduce diabetic complications and improve quality of life. Despite their broad benefits profile, the risk of genital tract infections, volume depletion, amputations and diabetic ketoacidosis associated with SGLT2i should be carefully monitored. In this compendium, we systematically reviewed the literature from Medline, Cochrane Library, and other relevant databases and attempted to provide evidence-based recommendations for the positioning of SGLT2i in the management of diabetes in the Indian population.Funding: AstraZeneca Pharma India Limited.

Temporal changes in the incidence and predictors of severe hypoglycaemia in type 2 diabetes: The Fremantle Diabetes Study

AIM

To determine the incidence of severe hypoglycaemia and its predictors in community-based patients with type 2 diabetes studied between 2008 and 2013 compared with those in a cohort of patients with type 2 diabetes from the same geographical area assessed a decade earlier.

METHODS

We studied 1551 participants (mean age 65.7 years, 51.9% men) with type 2 diabetes from the longitudinal observational Fremantle Diabetes Study Phase II (FDS2). Severe hypoglycaemia was ascertained as that requiring ambulance attendance, emergency department services and/or hospitalization. Cox proportional hazards modelling was used to determine predictors of a first episode of severe hypoglycaemia, and negative binomial regression was used to identify predictors of frequency.

RESULTS

Sixty-three participants (4.1%) experienced 83 episodes, representing an incidence of 1.34/100 participant-years (95% confidence interval [CI] 1.08 to 1.67; vs 1.67/100 participant-years [95% CI 1.31-2.13] in the Fremantle Diabetes Study Phase I [FDS1]; P = 0.18). Those experiencing severe hypoglycaemia experienced one to four episodes in both cohorts. The independent predictors of incident severe hypoglycaemia in the FDS2 were: older age; higher educational attainment; alcohol consumption; current smoking; sulphonylurea/insulin treatment; prior severe hypoglycaemia; renal impairment; and plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP). The same variables except smoking were associated with frequency of severe hypoglycaemia. Most of these risk factors paralleled those in the FDS1, but current smoking and plasma NT-proBNP were novel.

CONCLUSIONS

The incidence and frequency of severe hypoglycaemia did not change between the Fremantle Diabetes Study phases but novel risk factors, including plasma NT-proBNP, were observed in the FDS2.

Tofogliflozin decreases body fat mass and improves peripheral insulin resistance

The impact of tofogliflozin, a sodium-glucose co-transporter-2 inhibitor, on peripheral glucose uptake in patients with type 2 diabetes mellitus (T2DM) was investigated using the hyperinsulinaemic-euglycaemic clamp method in a single-arm, open-label study. The following variables were compared between before and after tofogliflozin administration for 12 weeks in 16 patients with T2DM who were receiving dipeptidyl peptidase-4 inhibitor treatment: body weight (BW); blood pressure; glucose metabolism; liver function; lipid profile; and body composition. Peripheral glucose uptake (M value and M/I ratio) was examined by the hyperinsulinaemic-euglycaemic clamp method. After 12 weeks, there was a significant decrease (P < .001) in glycated haemoglobin, BW, body fat mass and lean body mass. Peripheral glucose uptake, which indicates insulin sensitivity, increased significantly (M value by 0.90 and M/I ratio by 0.49; both P < .05). The change in the M value after 12 weeks of tofogliflozin therapy was correlated with the change in body fat mass (P < .05). Tofogliflozin significantly improved insulin sensitivity and peripheral glucose uptake in patients with T2DM. These improvements were significantly correlated with reduction in body fat mass.

Practical strategies for improving outcomes in T2DM: The potential role of pioglitazone and DPP4 inhibitors

T2DM is a complex disease underlined by multiple pathogenic defects responsible for the development and progression of hyperglycaemia. Each of these factors can now be tackled in a more targeted manner thanks to glucose-lowering drugs that have been made available in the past 2 to 3 decades. Recognition of the multiplicity of the mechanisms underlying hyperglycaemia calls for treatments that address more than 1 of these mechanisms, with more emphasis placed on the earlier use of combination therapies. Although chronic hyperglycaemia contributes to and amplifies cardiovascular risk, several trials have failed to show a marked effect from intensive glycaemic control. During the past 10 years, the effect of specific glucose-lowering agents on cardiovascular risk has been explored with dedicated trials. Overall, the cardiovascular safety of the new glucose-lowering agents has been proven with some of the trials summarized in this review, showing significant reduction of cardiovascular risk. Against this background, pioglitazone, in addition to exerting a sustained glucose-lowering effect, also has ancillary metabolic actions of potential interest in addressing the cardiovascular risk of T2DM, such as preservation of beta-cell mass and function. As such, it seems a logical agent to combine with other oral anti-hyperglycaemic agents, including dipeptidyl peptidase-4 inhibitors (DPP4i). DPP4i, which may also have a potential to preserve beta-cell function, is available as a fixed-dose combination with pioglitazone, and could, potentially, attenuate some of the side effects of pioglitazone, particularly if a lower dose of the thiazolidinedione is used. This review critically discusses the potential for early combination of pioglitazone and DPP4i.

A comparative safety review between GLP-1 receptor agonists and SGLT2 inhibitors for diabetes treatment

INTRODUCTION

Glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium glucose cotransporter 2 inhibitors (SGLT2i) are of particular interest in type 2 diabetes treatment strategies, due to their efficacy in reducing HbA1c with a low risk of hypoglycaemia, to their positive effects on body weight and blood pressure and in light of their effects on cardiovascular risk and on nephroprotection emerged from the most recent cardiovascular outcome trials. Since it is therefore very likely that GLP-1RA and SGLT2i use will become more and more common, it is more and more important to gather and discuss information about their safety profile.

AREAS COVERED

Adverse events and the safety concerns most often emerged in trials with GLP-1RA namely, exenatide long acting release (LAR), dulaglutide, liraglutide, semaglutide, lixisenatide or SGLT2i, namely empagliflozin, dapagliflozin, canagliflozin and SGLT2i with an attempt at comparing the safety profiles of molecules of these two classes.

EXPERT OPINION

GLP-1RA and SGLT2i, although each associated with different specific side effects, share a 'similar' safety profile and are both drugs relatively easy to handle. The potentially complementary mechanisms of action, the cardio and nephroprotective effects demonstrated by molecules of both classes, make these drugs potentially useful even in add on to each other.

Long-term safety and efficacy of canagliflozin as add-on therapy to teneligliptin in Japanese patients with type 2 diabetes

AIM

To evaluate the long-term safety and efficacy of canagliflozin as add-on therapy in patients with type 2 diabetes mellitus (T2DM) who had inadequate glycaemic control with teneligliptin monotherapy.

METHODS

This open-label 52-week study was conducted in Japan. Patients received canagliflozin 100 mg added to teneligliptin 20 mg orally once daily for 52 weeks. The safety endpoint was the incidence of adverse events (AEs). The efficacy endpoints included changes in glycated haemoglobin (HbA1c), fasting plasma glucose (FPG) and body weight from baseline to week 52 (with last observation carried forward).

RESULTS

Overall, 153 patients entered the treatment period and 142 completed the study. The overall incidence rates of AEs and drug-related AEs were 69.9% and 22.9%, respectively. Most AEs and drug-related AEs were mild or moderate in severity. There were no previously undescribed safety signals. The mean changes in HbA1c, FPG and body weight were -0.99% (95% confidence interval [CI] -1.12 to -0.85), -38.6 mg/dL (95% CI -43.4 to -33.9) and -3.92% (95% CI -4.53 to -3.31), respectively. These effects were maintained for 52 weeks without attenuation. HbA1c and body weight were both decreased in 82.24% of patients at the end of the treatment period. Reductions in postprandial glucose were observed at weeks 24 and 52.

CONCLUSIONS

No new safety risks with this combination were identified, and sustained improvements in HbA1c, FPG and body weight were observed. The findings suggest that long-term co-administration of canagliflozin with teneligliptin is well tolerated and effective in Japanese patients with T2DM who have inadequate glycaemic control on teneligliptin alone.

Changes in patient characteristics, glucose lowering treatment, glycemic control and complications in type 2 diabetes in general practices (Disease Analyzer, Germany: 2008-2016)

OBJECTIVES

The objectives were to examine long-term changes in type 2 diabetes patient characteristics, diabetes treatment, control and complications in general practices.

METHODS

All type 2 diabetes patients were identified in a representative general practice database (Disease Analyser, Germany) in three periods (01/2008-12/2008: n = 90.866, 818 practices, mean age (SD): 67.6 (12.1) years, 51% males; 01/2012-12/2012: n = 179.923, 1.158 practices, 68.3 (12.6) years, 51% males; 10/2015-09/2016: n = 201.667, 1.184 practices, 68.2 (12.9) years, 52% males). Chi-square and Wilcoxon rank-sum tests were used for testing differences (2008 vs. 2015/16).

RESULTS

The mean number of type 2 patients per practice increased (2008: 111; 2015/16: 170). The proportion of retirees declined (74% vs. 61%) and patients in the working population increased (18% vs. 28%) (all p < 0.001). There were no relevant changes in mean HbA1c (7.1% vs. 7.2%), fasting blood glucose (141 mg/dl vs. 144 mg/dl) and BMI (31 kg/m² vs. 32 kg/m²), whereas total cholesterol (204 mg/dl vs. 196 mg/dl) and triglycerides (159 mg/dl vs. 153 mg/dl) slightly declined (all p < 0.001). Prescription use of metformin, dipeptidyl peptidase-4 (DPP-4) and sodium dependent glucose transporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists enlarged (dual or triple combinations) while sulfonylurea use decreased. Prevalence of polyneuropathy (6.2% vs. 8.6%), nephropathy (1.9% vs. 3.2%) and depression (7.6% vs. 10.0%) rised (all p < 0.001).

CONCLUSIONS

General practitioners play a key role in diabetes care, increasingly treating type 2 diabetes patients in the working population. There was no change in glycemic control over the study period (2008-2016). The use of glucose-lowering drug combinations increased and microvascular complications were more often recorded.

Estimating the risk of severe hypoglycemic event related to glucose-lowering treatment among Italian patients with diabetes: the HYPOTHESIS database

The primary objective of this study was to estimate 1) the annual risk of undergoing a severe hypoglycemic event in Italian patients with diabetes and 2) the risk of hospitalization following such event. From the HYPOTHESIS database, powered by 46 emergency departments covering a 12-million-odd population, data were extracted of 1,922 hypoglycemic events occurring in patients with diabetes in 2011. The mean age was 71.5 (standard deviation 16.8) years, 50.1% were men, and blood glucose at the time of the event was 44.2 (26.5) mg/dL. Patients were being treated with insulin alone (55%) or in combination with oral hypoglycemic agents (OHA, 15%), or with OHA alone, either in monotherapy (14%) or in multiple therapy (16%). Comorbidities were recorded in 71.8% of the patients. Based on the rates of glucose-lowering drug use in Italian patients with diabetes, the annual risk of undergoing a serious hypoglycemic event was estimated at 1.27% for subjects treated with insulin alone, the highest (p<0.00001) as compared with insulin + OHA (0.41%) or OHA alone, either in monotherapy or in multiple therapy (0.1% and 0.17%, respectively). The risk of being hospitalized following the hypoglycemic event was the least (27.6%) for subjects treated with insulin alone (p<0.0083). Subjects treated with insulin + OHA showed a lower risk (34.2%) as compared with that for subjects treated with OHA (p<0.02). Death occurs in 7% of hospitalized patients. Older age (p<0.0001) and comorbidities (p<0.0001) were risk factors for hypoglycemia-related hospitalization. Treatments with insulin alone (p<0.005) or in combination (p<0.049) were negatively associated with hospital admission. Severe hypoglycemic events associated with the use of oral glucose-lowering agents carry the highest risk of hospital treatment. As such, they are also likely to generate higher tangible and intangible costs.

Combination SGLT2 inhibitor and GLP-1 receptor agonist therapy: a complementary approach to the treatment of type 2 diabetes

Among persons with type 2 diabetes (t2d), the development of glucose intolerance involves dysfunction in several organs and tissues, including the muscle, liver, pancreas, kidney, gastrointestinal tract, adipose tissue, and brain. individuals with t2d typically have a number of comorbidities, including hypertension, hyperlipidemia, and being overweight or obese, and are, consequently, at high cardiovascular risk. guidelines recommend a comprehensive care strategy that includes treatment of diabetes-related complications and comorbidities beyond those related to hyperglycemia. use of glucose-lowering therapies with complementary activities that address multiple facets of the disease may improve long-term outcomes for patients with t2d. two recent drug classes developed for use in t2d, glucagon-like peptide-1 receptor agonists (glp-1ras) and sodium glucose cotransporter 2 (sglt2) inhibitors, have been shown in clinical trials to have beneficial effects on glycemic control, body weight, cardiovascular risk factors, and (for liraglutide, semaglutide, and empagliflozin) cardiovascular outcomes, while having an acceptable safety profile. between them, these drug classes directly or indirectly affect many of the organs and tissues involved in the pathogenesis of t2d, and their beneficial effects on glycemic- and cardiovascular-related parameters are likely to be complementary and potentially additive. in the largest clinical trial of a glp-1ra and an sglt2 inhibitor in combination (duration-8), patients with t2d (n = 685) who received exenatide plus dapagliflozin added to their treatment regimen for 28 weeks had significantly greater reductions from baseline in glycated hemoglobin, body weight, and systolic blood pressure compared with patients who received either drug as monotherapy. this review summarizes the complementary aspects of these drug classes and presents the available data among patients receiving dual therapy with a glp-1ra and an sglt2 inhibitor.

Changes in Glycemic Control and Body Weight After Initiation of Dapagliflozin or Basal Insulin Supported Oral Therapy in Type 2 Diabetes: A Primary Care Database Study

BACKGROUND

The aim was to compare changes in HbA1c and body weight after initiation of dapagliflozin or basal insulin supported oral therapy (BOT) in type 2 diabetes patients in primary care practices.

METHODS

Patients from 983 primary care practices who started dapagliflozin or BOT between December 2012 and July 2015 (index date, ID) were retrospectively analyzed (Disease Analyzer; Germany). Changes in HbA1c (%) and body weight (kg) were evaluated 90-270 days after ID. Propensity score (PS) matching (1:1) was used to adjust for differences in baseline clinical characteristics (180-0 days before ID: age, sex, health insurance, diabetologist care, glucose lowering therapy, HbA1c, body mass index) and duration (days) between start of therapies and last HbA1c or weight documentation after ID.

RESULTS

After PS matching, 766 dapagliflozin (mean ± SD; age: 63 ± 10 years; HbA1c: 8.9 ± 1.2%) and 766 BOT (age: 63 ± 10 years; HbA1c: 8.7 ± 1.1%) patients were included. HbA1c decreased by mean (SD) of 1.0% (1.3) in dapagliflozin and by 1.0% (1.4) in BOT patients after 90-270 days (HbA1c reduction; dapagliflozin vs BOT: -0.01%; P = .79). In 440 dapagliflozin users with available data, body weight (97.4 ± 19.9 kg) decreased by 3.1 (5.8) kg after 90-270 days, whereas no significant weight change was observed in 440 matched BOT patients (97.5 ± 19.9 kg) (weight reduction; dapagliflozin vs BOT: -3.0 kg; P < .05).

CONCLUSIONS

Initiation of dapagliflozin therapy reduced HbA1c similar to basal insulin with the additional benefit of weight reduction in type 2 diabetes patients treated in general practices.

Association of dipeptidyl peptidase 4 inhibitors with risk of metastases in patients with type 2 diabetes and breast, prostate or digestive system cancer

AIMS

Experimental and animal studies have supported the hypothesis that dipeptidyl peptidase-4 inhibitors (DPP-4i) may accelerate tumor metastasis. The aim was to analyze the relationships between DPP-4i therapy with risk of metastases in type 2 diabetes patients with breast, prostate and digestive organ cancers.

METHODS

Type 2 diabetes patients with first diagnoses of breast, prostate or digestive organ cancer were selected in general and internal medicine practices (Disease Analyzer Germany: 01/2008-12/2014). Propensity score matching between DPP-4i users and non-users was carried out for age, sex, diabetes duration, and metformin use. Time-dependent Cox regression models were used to estimate hazard ratios (HR) for metastases further adjusting for HbA1c, body mass index, comorbidity and co-therapy with glucose-lowering drugs (3-4years follow-up).

RESULTS

668 patients with newly diagnosed breast cancer, 906 with prostate cancer and 908 with digestive organ cancer were analyzed. In Cox regression, use of DPP-4i was not associated with an increased risk of metastases in patients with breast (adjusted HR, 95%CI: 1.00, 0.49-2.02), prostate (0.98, 0.54-1.77) or digestive organ cancers (0.97, 0.57-1.66).

CONCLUSIONS

This first observational study in patients with type 2 diabetes and breast, prostate or digestive organ cancer found no increased risk of metastases in DPP-4i users.

Outcomes of laparoscopic sleeve gastrectomy in elderly obese Japanese patients

AIM

Laparoscopic sleeve gastrectomy (LSG) has proven to be the most effective strategy for the treatment of morbid obesity, however its efficacy and safety in an aging population has not yet been confirmed. In this study, we evaluated the effectiveness and safety of LSG in elderly obese Japanese patients.

METHODS

Three obese individuals aged >60 years and 11 obese individuals aged <60 years who underwent LSG were enrolled. Pre- and postoperative changes after at least 12 months were examined, including bodyweight, body mass index, total weight loss, excess weight loss, bone mineral density and bone-related markers.

RESULTS

There were no significant differences between patients aged <60 years and >60 years in terms of percent total weight loss (24.4 ± 11 vs 23 ± 4.4%, respectively) and percent excess weight loss (49.1 ± 23.4 vs 47.6 ± 10 %, respectively). Dual-energy X-ray absorptiometry was carried out before and 12 months after LSG. There were no significant differences in bone mineral density changes at the lumbar spine and femoral neck between the two groups (0.01 ± 0.06 vs 0.02 ± 0.03 g/cm² , -0.03 ± 0.06 vs -0.08 ± 0.02 g/cm² , respectively). There were no peri- and postoperative complications. All three patients aged >60 years had reduced bone mineral density in the femoral neck after LSG; one was diagnosed with osteoporosis.

CONCLUSIONS

Although the present results suggest that LSG could be of considerable benefit to elderly obese Japanese patients, long-term careful observation after bariatric surgery is especially important in elderly patients to prevent future osteoporosis. Geriatr Gerontol Int 2017; 17: 2068-2073.

Perspectives on cardiovascular effects of incretin-based drugs: From bedside to bench, return trip

Recently, cardiovascular outcome trials with glucose-lowering drugs used in type 2 diabetes mellitus, namely glucagon-like peptide-1 receptor agonists (GLP-1RA), liraglutide and semaglutide, showed a reduction in cardiovascular events, which had not been observed in trials with other incretin-based drugs, such as lixisenatide or with dipeptidyl peptidase-4 inhibitors (DPP4i). Mechanisms underlying the observed cardiovascular differences between DPP4i and GLP1-RA, and across individual GLP1-RA are poorly understood. This review is aimed at collecting and summarizing available evidence from experimental and mechanistic studies on the action of GLP1-RA and DPP4i on the cardiovascular system, both deriving from clinical and pre-clinical sources. The results of cardiovascular outcome trials are interpreted on the basis of the experimental preclinical data available, paying particular attention to the heart failure results, and suggesting some novel intriguing hypotheses to explain some of the unexpected findings of cardioprotection of incretin-based drugs. In particular, we discuss the possible contribution to the incretin cardiovascular effects of a direct cardiac action of GLP-1 metabolites through GLP-1 receptor-independent pathways, and of DPP4 substrates other than GLP-1.

Real-world effectiveness and safety of dapagliflozin therapy added to a GLP1 receptor agonist in patients with type 2 diabetes

BACKGROUND AND AIM

To evaluate the effectiveness and safety of a sodium-glucose cotransporter-2 (SGLT-2) inhibitor, dapagliflozin, in patients with type 2 diabetes mellitus (T2DM) and background glucagon-like peptide-1 receptor agonist (GLP1-RA) therapy.

METHODS AND RESULTS

This is a 12-month, real-world observational study, which assessed the effectiveness and safety of dapagliflozin in patients with T2DM and background GLP1-RA therapy. The main outcome measures were changes in A1C and weight at 6 and 12 months from baseline. Secondary outcomes were differences in A1C and weight reduction between this cohort and another group of patients with T2DM treated with dapagliflozin but without background GLP1-RA therapy. In total, 109 patients with GLP1-RA and 104 patients without GLP1-RA were included. Baseline mean A1C and weight in the GLP1-RA and non-GLP1-RA groups were 7.4% vs. 7.3% and 96.2 kg vs. 95.1 kg, respectively. A significant reduction in A1C was seen with dapagliflozin in both cohorts at 6 and 12 months (GLP1-RA: -0.51% and -0.34%, non-GLP1-RA: -0.69% and -0.62%, respectively, p < 0.0001 in all analyses). Weight was significantly reduced in both groups at 6 and 12 months (GLP1-RA: -2.3 kg and -2.4 kg, non-GLP1-RA: -3.9 kg and -4.8 kg, respectively, p < 0.0001 in all analyses). A1C reduction and weight loss were significantly lower in patients with GLP1-RA than in patients without GLP1-RAs. Drug discontinuation rates were similar in both cohorts.

CONCLUSIONS

Dapagliflozin, when added in real life to patients with T2DM treated with GLP1-RAs, induced a further significant, albeit modest improvement in A1C and a further weight loss.

Clinical inertia to insulin initiation and intensification in the UK: A focused literature review

Achieving tight glycaemic control early following the diagnosis of type 2 diabetes is key to optimising clinical outcomes, yet many patients and clinicians are reluctant to initiate and intensify insulin therapy. Reasons for this arise primarily from a lack of time, clinical expertise and patient understanding. However, meaningful progress can be achieved with self-management educational programmes soon after diagnosis. Clinician education and training, along with easy-to-use and well-tolerated therapies (for example, those carrying a low risk of hypoglycaemia and/or avoiding weight gain), may also increase the likelihood of patient adherence.

Treatment of Dyslipidemias to Prevent Cardiovascular Disease in Patients with Type 2 Diabetes

PURPOSE OF REVIEW

Current preventive and treatment guidelines for type 2 diabetes have failed to decrease the incidence of comorbidities, such as dyslipidemia and ultimately heart disease. The goal of this review is to describe the physiological and metabolic lipid alterations that develop in patients with type 2 diabetes mellitus. Questions addressed include the differences in lipid and lipoprotein metabolism that characterize the dyslipidemia of insulin resistance and type 2 diabetes mellitus. We also examine the relevance of the new AHA/ADA treatment guidelines to dyslipidemic individuals.

RECENT FINDINGS

In this review, we provide an update on the pathophysiology of diabetic dyslipidemia, including the role of several apolipoproteins such as apoC-III. We also point to new studies and new agents for the treatment of individuals with type 2 diabetes mellitus who need lipid therapies. Type 2 diabetes mellitus causes cardiovascular disease via several pathways, including dyslipidemia characterized by increased plasma levels of apoB-lipoproteins and triglycerides, and low plasma concentrations of HDL cholesterol. Treatments to normalize the dyslipidemia and reduce the risk for cardiovascular events include the following: lifestyle and medication, particularly statins, and if necessary, ezetimibe, to significantly lower LDL cholesterol. Other treatments, more focused on triglycerides and HDL cholesterol, are less well supported by randomized clinical trials and should be used on an individual basis. Newer agents, particularly the PCSK9 inhibitors, show a great promise for even greater lowering of LDL cholesterol, but we await the results of ongoing clinical trials.