The benefits of GLP1 receptors in cardiovascular diseases

Cardiovascular outcomes of glucagon-like peptide-1 agonist in patients with obesity and hypertrophic cardiomyopathy

BACKGROUND

Obesity is highly prevalent in patients with hypertrophic cardiomyopathy (HCM) and associated with a more severe phenotype and worse outcomes. Glucagon-like peptide-1 (GLP-1) receptor agonists have recently been shown to improve cardiovascular outcomes in patients with obesity. However, their impact on patients with obesity and HCM is unclear. Therefore we sought to assess the safety and efficacy of GLP-1 agonists in patients with obesity and HCM.

METHODS

Using the TriNetX Global Research Network, patients with HCM and BMI ≥30 kg/m2 were identified from 2016 to 2024 and classified into those who received GLP-1 agonists and those who did not. Groups were propensity matched to control for baseline confounders and evaluated for outcomes including all-cause mortality, heart failure hospitalization and arrhythmias.

RESULTS

Of 29,521 patients with HCM, 1553 (5 %) received GLP-1 agonists. After propensity score matching, both groups (n = 1497 in each) had comparable baseline characteristics. Over a 2-year follow-up period, patients with HCM on GLP-1 agonists had a significant reduction in BMI and lower all-cause mortality and HF hospitalization rates compared to patients not on GLP-1 agonists. In contrast, there was no significant differences in new-onset atrial fibrillation or ventricular arrhythmia, nor was there a significant difference in safety events related to GLP-1 agonists use.

CONCLUSION

In this large real-world dataset, the use of GLP-1 agonists in patients with obesity and HCM was associated with improved survival and lower rates of HF hospitalization. These data support future large prospective clinical trials of GLP-1 agonists in patients with obesity and HCM.

Diabetes Mellitus and Associated Vascular Disease: Pathogenesis, Complications, and Evolving Treatments

Diabetes mellitus is a metabolic disorder, characterized by elevated blood sugar levels (hyperglycemia) and insulin dysregulation. This disease is associated with morbidity and mortality, including significant potential vascular complications. High levels of hyperglycemia lead to not only elevated levels of reactive oxygen species but also advanced glycation end products, which are detrimental to the vascular endothelium and reduce protective compounds such as nitric oxide and prostacyclin. This damage contributes to the development of both macrovascular and microvascular complications. The present investigation explores the pathophysiological mechanisms of diabetic vascular complications and evaluates current management strategies, including lifestyle modifications, pharmacological treatments, and emerging therapies. The review underscores the importance of ongoing progress in diabetes management and patient education to lead to optimal patient-health outcomes and quality of life for individuals with diabetes mellitus.

Renoprotective mechanisms of glucagon-like peptide-1 receptor agonists

Glucagon-like peptide-1 (GLP-1) is an incretin hormone, secreted from gut endocrine cells, which acts to potentiate nutrient-induced insulin secretion. Activation of its receptor, GLP-1R, decreases glucagon secretion and gastric emptying, thereby decreasing blood glucose and body weight. It is largely through these mechanisms that Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have transformed the treatment of type 2 diabetes. More recently, preclinical and clinical studies have reported that these agents have potent extra-pancreatic effects, exhibiting cardioprotective and renoprotective actions. The recent FLOW trial was the first multicentre clinical trial investigating the effect of GLP-1RAs on a primary renal outcome and reported robust evidence that GLP-1RAs are renoprotective. Studies in rodent models of renal injury have shown that gain and loss of GLP-1R signalling improves or deteriorates kidney function. However, the precise mechanisms responsible for renal benefits of GLP-1RAs are not yet fully understood. While prolonged activation of GLP-1 receptors (GLP-1R) has been shown to reverse diabetes-related disruptions in gene expression across various renal cell populations, GLP-1R expression in both rodent and human kidneys is thought to be primarily confined to certain vascular smooth muscle cells. This review discusses recent advances in our understanding of the effects of GLP-1 medicines on the kidney with a focus on indirect and direct mechanisms of action.

Metabolic interventions as adjunctive therapies to insulin in type 1 diabetes: Current clinical landscape and perspectives

Type 1 diabetes (T1D) is classically characterized as an autoimmune disease wherein the immune system erroneously attacks insulin-producing pancreatic β-cells, causing insulin insufficiency and severe metabolic dysregulation. However, intensive investigation and numerous clinical trials with immunotherapies have been largely unable to significantly alter the course of disease. Currently, there is no effective way to prevent or cure T1D, and insulin remains the cornerstone of T1D treatment. In recent years, a growing body of research suggests that β-cells actively contribute to the immune response and to disease development. Factors including glucotoxicity, lipotoxicity, inflammation, endoplasmic reticulum (ER) and oxidative stress can induce β-cell apoptosis and senescence, further promoting insulitis. Recent studies highlight the importance of targeting metabolic control for T1D management and treatment. Metabolic interventions, through their direct and indirect impacts on β-cells, have shown promise in preserving β-cell function. These interventions can reduce glucose toxicity, alleviate oxidative stress and inflammation, enhance insulin sensitivity, and indirectly mitigate the autoimmune responses. By preserving β-cell function, individuals with T1D attain better glycaemic control, reduced complication risks and exhibit improved overall metabolic health. Here, we provide an overview of insights from clinical studies, systematic reviews and meta-analyses that collectively demonstrate that adjunctive metabolic interventions can enhance glycaemic control, reduce insulin requirements and mitigate adverse effects associated with insulin monotherapy. They also show potential for halting disease progression, preserving residual β-cell function and improving long-term outcomes for newly diagnosed individuals. Future research should focus on optimizing these treatment strategies and establishing their long-term efficacy and safety.

Comparative Cardiovascular and Renal Outcomes of Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists in Type 2 Diabetes: A Systematic Review

This systematic review evaluates the cardiovascular and renal outcomes associated with sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists in patients with type 2 diabetes, focusing on findings from randomized controlled trials. A comprehensive search was conducted across PubMed, Embase, and the Cochrane Library, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seven high-quality trials met the inclusion criteria, with a combined focus on major adverse cardiovascular events (MACE), heart failure hospitalizations, all-cause and cardiovascular mortality, and renal function decline. SGLT2 inhibitors demonstrated superior efficacy in reducing heart failure and renal outcomes, while GLP-1 receptor agonists were more effective in preventing MACE and improving glycemic control. Combination therapy showed potential additive benefits, particularly in improving myocardial and arterial function. The findings highlight the complementary roles of these drug classes, underscoring the importance of personalized therapy based on individual patient profiles. Further research, including long-term head-to-head trials, is warranted to validate these results and optimize treatment strategies.

Effect of glucagon-like peptide-1 receptor agonists on vascular risk factors among adults with type 2 diabetes and established atherosclerotic cardiovascular disease

Introduction

Limited data exist on the cardiovascular effectiveness of once-weekly (OW) glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in real-world practice.

Methods

We assessed the OW GLP-1 RA effects on vascular risk factors in adults with type 2 diabetes and atherosclerotic cardiovascular disease using data from a large-scale US electronic health record database (index date = first prescription of OW GLP-1 RA). Exploratory analyses were performed on patients newly initiating OW GLP-1 RAs with semaglutide, OW GLP-1 RAs without semaglutide, and semaglutide. Changes in vascular risk factors were evaluated by comparing mean measures between the 12-month pre- and post-index periods. Analyses were conducted for all three cohorts and subpopulations including stratified by tercile of baseline vascular risk factor value.

Results

In the final cohorts ([1] OW GLP-1 RA including semaglutide: n = 20,084; [2] OW GLP-1 RA excluding semaglutide: n = 16,894; [3] semaglutide: n = 3,435), significant mean reductions (P < 0.001) were observed from baseline to post-index in hemoglobin A1c (%, [1] -1.1; [2] -1.1; [3] -1.2), low-density lipoprotein cholesterol (mg/dL, [1] -6.4; [2] -6.4; [3] -6.9), total cholesterol (mg/dL, [1] -11.0; [2] -11.1; [3] -10.7), triglycerides (mg/dL, [1] -31.8; [2] -31.4; [3] -33.1), systolic blood pressure (mmHg, [1] -1.5; [2] -1.2; [3] -3.1), body weight (kg, [1] -2.7; [2] -2.4; [3] -4.3) and body mass index (kg/m2; [1] -0.9; [2] -0.8; [3] -1.4). Largest reductions were observed in the top tercile.

Conclusion

Our data suggest GLP-1 RAs are associated with significant reductions in key vascular risk factors in real-world practice.

Can Lp(a) become the next A1C? A case for digital health management tools to overcome inertia to Lipoprotein (a) testing

Despite its known correlations with risk of cardiovascular disease, awareness and testing for Lipoprotein (a) lags that of other serological markers with estimates that less than 1% of the US population have undergone screening. Herein we outline how digital tools framed around motivational models (COM-B and SEM), might help increase likelihood of patients seeking Lp(a) testing as part of their managed care. Furthermore, we highlight how recent trends in prescription of GLP-1 receptor antagonists are serving to motivate patients to manage biomarkers related to T2D and obesity, which are also relevant in cardiovascular disease. Capitalizing on this trend to stimulate interest in Lp(a) management could have near term consequence, and with disease modifying therapies in development ultimately improve outcomes in cardiovascular disease.

Effects of Weight Loss on Endothelium and Vascular Homeostasis: Impact on Cardiovascular Risk

Available knowledge shows that obesity is associated with an impaired endothelial function and an increase in cardiovascular risk, but the mechanisms of this association are not yet fully understood. Adipose tissue dysfunction, adipocytokines production, along with systemic inflammation and associated comorbidities (e.g., diabetes and hypertension), are regarded as the primary physiological and pathological factors. Various strategies are now available for the control of excess body weight. Dietary regimens alone, or in association with bariatric surgery when indicated, are now widely used. Of particular interest is the understanding of the effect of these interventions on endothelial homeostasis in relation to cardiovascular health. Substantial weight loss resulting from both diet and bariatric surgery decreases circulating biomarkers and improves endothelial function. Extensive clinical trials and meta-analyses show that bariatric surgery (particularly gastric bypass) has more substantial and long-lasting effect on weight loss and glucose regulation, as well as on distinct circulating biomarkers of cardiovascular risk. This review summarizes the current understanding of the distinct effects of diet-induced and surgery-induced weight loss on endothelial function, focusing on the key mechanisms involved in these effects.

Diabetic Ketoacidosis and the Use of New Hypoglycemic Groups: Real-World Evidence Utilizing the Food and Drug Administration Adverse Event Reporting System

Background: Diabetic ketoacidosis (DKA), a life-threatening complication, can occur in individuals with type 2 diabetes during illness, stress, or medication use. This study examines DKA signals in type 2 diabetes, focusing on sodium-glucose cotransporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and dipeptidyl-peptidase-4 (DPP-4) inhibitors. Methods: DKA reports from Q1 2019 to Q3 2024 were retrieved from the FDA Adverse Event Reporting System (FAERS). Associations between primary exposure and outcomes were ascertained using four key metrics: Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Empirical Bayes Geometric Mean (EBGM), and Information Component (IC). Results: SGLT2 inhibitors exhibited the higher DKA risk in 2019-2021 (ROR: 314.86 [95% CI 301.76-328.53], PRR of 245.69 [95% CI 235.47-256.36], IC of 6.90, and EBGM of 120), declining in 2022-2024. GLP-1 receptor agonists showed an ROR increase from 2.88 [95% CI 2.56-3.25] in 2019-2021 to 4.64 [95% CI 4.06-5.29] in 2022-2023, slightly declining to 3.95 [95% CI 3.27-4.74] in 2024. DPP-4 inhibitors exhibited a steady ROR rise from 6.81 [95% CI 5.52-8.40] in 2019-2021 to 8.57 [95% CI 6.24-11.76] in 2022-2023 and further to 11.02 [95% CI 6.71-18.10] in 2024. PRR, EBGM, and IC values followed similar trends. The age groups 41-60 and 61-91 years were the most affected, with hospitalization at its highest rate for DPP4-inhibitors in Q1-Q3 of 2024. Hospitalizations were also observed with GLP-1 receptor agonists and SGLT2 inhibitors. Life-threatening events and fatalities were also reported, with physicians contributing to most reports. Conclusions: DKA signals were observed for all three drug classes, particularly among elderly patients, highlighting the need for careful monitoring, especially during periods of illness or stress. However, the risk was higher in the SGLT2 inhibitor group than in the other groups.

Interactions between antidiabetes medications and heart-brain axis

PURPOSE OF REVIEW

The heart - brain axis (HBA) is the physiological interactions between the cardiovascular and nervous systems through autonomic nerves, hormones, and cytokines. Patients diagnosed with diabetes mellitus have an increased risk of the cardiovascular and neurological diseases. However, recent evidence demonstrated that different antidiabetic drugs may delay cognitive impairment and improve cardiovascular outcomes. This review examines the impact of antidiabetic drugs on the HBA in patients with diabetes.

RECENT FINDINGS

Metformin improves the cardiovascular and cognitive outcomes through adenosine 5'-monophosphate-activated protein kinase activation. Sodium-glucose cotransporter-2 inhibitors reduce inflammation, oxidative stress by inhibiting the NLRP3 inflammasome thereby reducing the incidence of heart failure and formation of beta-amyloid and neurofibrillary tangles in the brain. Dipeptidyl peptidase-4 inhibitors exhibit neuroprotective effects in Alzheimer's disease by reducing amyloid-beta and tau pathology and inflammation but may exacerbate heart failure risk due to increased sympathetic activity and prolonged β-adrenergic stimulation. Glucagon-like peptide-1 receptor agonists exhibit neuroprotective effects in Alzheimer's and Parkinson's diseases by reducing neuroinflammation, but may increase sympathetic activity, potentially elevating heart rate and blood pressure, despite their cardioprotective benefits.

SUMMARY

Antidiabetes medications have the potential to improve cardiovascular and cognitive outcomes; however, additional studies are required to substantiate these effects.

Association of GLP-1 Receptor Agonists With Risk of Suicidal Ideation and Behaviour: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are widely used to treat type 2 diabetes and obesity, providing metabolic and cardiovascular benefits. However, concerns have emerged about potential neuropsychiatric side effects, including suicidal ideation and behaviour, prompting investigations by regulatory bodies such as the FDA and EMA. This systematic review and meta-analysis aimed to assess the association between GLP-1RA use and the risk of suicidal ideation or behaviour.

METHODS

A systematic literature search was conducted in PubMed, Embase, and Web of Science through September 2024, adhering to PRISMA guidelines. Observational cohort and case-control studies reporting suicidal ideation or behaviour in adults using GLP-1RAs were included. The Modified Newcastle-Ottawa Scale assessed risk of bias, and random-effect models calculated risk ratios (RR) with 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 statistic.

RESULTS

Of 126 studies, 11 were included from multiple countries with diverse designs. The meta-analysis of four studies showed no statistically significant difference in suicidal outcomes between GLP-1RA users and users of other anti-hyperglycaemic drugs (RR: 0.568, 95% CI: 0.077-4.205). Substantial heterogeneity was observed (I2 = 98%). Pharmacovigilance studies indicated no disproportionate increase in suicidality, while some observational studies suggested a lower risk.

CONCLUSION

This review found no significant link between GLP-1RA use and increased suicidal ideation or behaviour. However, the high heterogeneity and reliance on pharmacovigilance data suggest caution. Clinicians should monitor patients, particularly those with psychiatric conditions, and further research is needed to assess long-term neuropsychiatric safety.

Heme oxygenase, biliverdin reductase, and bilirubin pathways regulate oxidative stress and insulin resistance: a focus on diabetes and therapeutics

Metabolic and insulin-resistant diseases, such as type 2 diabetes mellitus (T2DM), have become major health issues worldwide. The prevalence of insulin resistance in the general population ranges from 15.5% to 44.6%. Shockingly, the global T2DM population is anticipated to double by 2050 compared with 2021. Prior studies indicate that oxidative stress and inflammation are instrumental in causing insulin resistance and instigating metabolic diseases. Numerous methods and drugs have been designed to combat insulin resistance, including metformin, thiazolidinediones (TZDs), sodium-glucose cotransporter 2 inhibitors (SGLT2i), glucagon-like peptide 1 receptor agonists (GLP1RA), and dipeptidyl peptidase 4 inhibitors (DPP4i). Bilirubin is an antioxidant with fat-burning actions by binding to the PPARα nuclear receptor transcription factor, improving insulin sensitivity, reducing inflammation, and reversing metabolic dysfunction. Potential treatment with antioxidants like bilirubin and increasing the enzyme that produces it, heme oxygenase (HMOX), has also gained attention. This review discusses the relationships between bilirubin, HMOX, and insulin sensitivity, how T2DM medications affect HMOX levels and activity, and potentially using bilirubin nanoparticles to treat insulin resistance. We explore the sex differences between these treatments in the HMOX system and how bilirubin levels are affected. We discuss the emerging concept that bilirubin bioconversion to urobilin may have a role in metabolic diseases. This comprehensive review summarizes our understanding of bilirubin functioning as a hormone, discusses the HMOX isoforms and their beneficial mechanisms, analyzes the sex differences that might cause a dichotomy in responses, and examines the potential use of HMOX and bilirubin nanoparticle therapies in treating metabolic diseases.

Glucagon-Like Peptide-1 Receptor Agonists in the Peri-Operative Period

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are emerging as an important class of drugs in the management of Type 2 Diabetes Mellitus (T2DM) and obesity. There are rising concerns of pulmonary aspiration with these medications due to drug-induced gastroparesis. While definitive association is uncertain, it is essential to be prudent and manage these patients as per the current evidence and recommendations.

Neuroprotective effects of GLP-1 receptor agonists in neurodegenerative Disorders: A Large-Scale Propensity-Matched cohort study

BACKGROUND

GLP-1 receptor agonists, traditionally used for treating type 2 diabetes mellitus and obesity, have demonstrated anti-inflammatory properties. However, their potential neuroprotective effects in neurodegenerative disorders remain unclear.

OBJECTIVE

To evaluate the impact of GLP-1 receptor agonists on the risk of developing various neurodegenerative conditions in obese patients.

METHODS

This comprehensive retrospective cohort study analyzed data from 5,307,845 obese adult patients across 73 healthcare organizations in 17 countries. Propensity score matching was performed, resulting in 102,935 patients in each cohort. We compared the risk of developing neurodegenerative disorders between obese patients receiving GLP-1 receptor agonist therapy and those who were not.

RESULTS

Obese patients treated with GLP-1 receptor agonists showed significantly lower risks of developing Alzheimer's disease (RR = 0.627, 95 %CI = 0.481-0.817), Lewy body dementia (RR = 0.590, 95 %CI = 0.462-0.753), and vascular dementia (RR = 0.438, 95 %CI = 0.327-0.588). The risk reduction for Parkinson's disease was not statistically significant overall (RR = 0.784, 95 %CI = 0.580-1.058) but was significant for semaglutide users (RR = 0.574, 95 %CI = 0.369-0.893). Semaglutide consistently showed the most pronounced protective effects across all disorders. Additionally, a significant reduction in all-cause mortality was observed (HR = 0.525, 95 %CI = 0.493-0.558).

CONCLUSION

This study provides evidence that the effects of GLP-1 receptor agonists may extend beyond their known metabolic and cardioprotective benefits to include neuroprotection, associated with a decreased risk of developing various neurodegenerative disorders. These findings suggest the potential for expanding the therapeutic applications of GLP-1 receptor agonists to improve neurocognitive outcomes. Further research is warranted to elucidate the mechanisms underlying these neuroprotective effects and to explore their clinical applications in neurodegenerative disease prevention and treatment.

New and future heart failure drugs

In the past decade, our understanding of heart failure pathophysiology has advanced significantly, resulting in the development of new medications such as angiotensin-neprilysin inhibitors, sodium-glucose cotransporter-2 inhibitors and oral soluble guanylate cyclase stimulators. Backed by positive findings from large randomized controlled trials, recommendations for their use were recently included in the 2022 AHA/ACC/HFSA guidelines and 2023 ESC guidelines for management of heart failure. Promising drugs for future heart failure treatment include agents that modulate the neurohormonal system, vasodilators, anti-inflammatory drugs, mitotropes, which improve deranged energy metabolism of the failing heart, and myotropes, which increase cardiac contractility by affecting cardiac sarcomere function. Here, we discuss these new and future heart failure drugs. We explain their mechanisms of action, critically evaluate their performance in clinical trials and summarize the clinical scenarios in which the latest guidelines recommend their use. This Review aims to offer clinicians and researchers a comprehensive overview of novel therapeutic classes in heart failure treatment.

Impact of glucagon-Like peptide-1 agonists in optimizing abdominal wall Reconstruction patients

PURPOSE

Pre-optimization of obese patients prior to abdominal wall reconstruction (AWR) is essential in mitigating their increased preoperative risks. Traditionally diet, exercising, bariatric surgery are the tools typically prescribed for weight loss. The advent of glucagon-like peptide-1 agonists (GLP-1A) which stimulate insulin secretion and inhibit gastric emptying have improved the weight loss armamentarium. However, there is a limited amount of literature on GLP-1A effectiveness and postoperative outcomes in AWR patients. This study compares the efficacy of GLP-1A to Bariatric Surgery (BAS) in perioperative AWR patient.

METHODS

A prospectively maintained database was retrospectively reviewed to identify all patients undergoing AWR at our institution between January 2021 and March 2024. We included patients who required GLP-1A or BAS for weight optimization prior to AWR. We excluded patients on GLP1-A or history BAS not performed for AWR preoptimization. Basic demographics such as age, sex, race, weight and BMI at initial clinic visit and at surgery were compared. Primary endpoints included time to surgery, time to bowel recovery and length of stay (LOS). Time to surgery was defined as the number of months between the initial clinic visit and AWR. Time to bowel recovery was defined as the number of days it took for the first postoperative bowel function. Secondary endpoints included standard 30-days postoperative variables. Nominal variables were analyzed using a Fisher exact test and continuous variables were analyzed with Student's T test.

RESULTS

35 patients were included in this study (GLP-1A: 17, BAS: 18). The GLP-1A cohort had a lesser BMI at the initial clinic visit (40.8 vs 43.4, p = 0.188). GLP-1A cohort made it to the operating room faster (9.1 months vs 13.5 months, p = 0.06) from the first clinic visit; and (7.9 months vs 9.7 months, p = 0.4) from initiation of weight loss intervention. Albeit losing less weight (14.9 kg vs 27.1 kg, p = 0.008) with a lesser reduction in the BMI (4.69 vs 9.23, p = 0.004). The GLP-1A cohort showed a non-significant elevated LOS (5.2 days vs 3.6 days, p = 0.25) and an increased ileus rate (17.6% vs 0%, p = 0.1). However, there were no differences noted in time to bowel recovery (2.9 days vs 3.1 days, p = 0.76).

CONCLUSION

GLP-1A is effective in optimizing patients needing weight loss before AWR. They shorten the timeline to AWR intervention and have comparable peri-operative outcomes to BAS patients.

Bridging the Gap Between Diabetes and Cardiovascular Disease: A Comparative Review of Different Glucagon-Like Peptide-1 (GLP-1) Agonists: Efficacy, Safety, and Patient Outcomes

Diabetes mellitus, particularly Type 2 diabetes (T2DM) remains a significant concern globally with an increase in prevalence reported in recent years. If diabetes is not managed properly, it can lead to several complications including an increased risk of cardiovascular disease (CVD). Cardiovascular complications such as coronary heart disease, peripheral artery disease, and stroke are common among individuals with diabetes. Therefore, the timely management of diabetes becomes very important. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as a promising class of medications that offer benefits beyond glycemic control. Among various benefits, GLP-1 RAs can promote pancreatic β-cell proliferation and reduce their apoptosis. They also exert central effects on appetite and energy balance. Furthermore, the weight-lowering potential of GLP-1 RAs has also been documented in literature which can provide indirect benefit to CVD prevention. Long-term GLP-1 RAs generally have superior efficacy over short-term GLP-1 RAs in terms of controlling overnight and fasting plasma glucose levels. However, short-acting GLP-1 RAs, such as exenatide and lixisenatide, maintain their influence on gastric emptying during prolonged use. Adverse events, particularly, gastrointestinal adverse events, remain a concern with GLP-1 RA use. These symptoms usually appear at the start of treatment but fade as the body adjusts to the medication. GLP-1 RAs have shown beneficial effects on cardiovascular health, including a reduction in the incidence of major adverse cardiovascular events. In conclusion, GLP-1 RAs provide multifaceted benefits in T2DM as they not only maintain glycemic control but also decrease cardiovascular risk.

A Scoping Review of GLP-1 Receptor Agonists: Are They Associated with Increased Gastric Contents, Regurgitation, and Aspiration Events?

Background: The increased popularity and ubiquitous use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for the treatment of diabetes, heart failure, and obesity has led to significant concern for increased risk for perioperative aspiration, given their effects on delayed gastric emptying. This concern is highlighted by many major societies that have published varying guidance on the perioperative management of these medications, given limited data. We conducted a scoping review of the available literature regarding the aspiration risk and aspiration/regurgitant events related to GLP-1 RAs. Methods: A librarian-assisted search was performed using five electronic medical databases (PubMed, Embase, and Web of Science Platform Databases, including Web of Science Core Collection, KCI Korean Journal Database, MEDLINE, and Preprint Citation Index) from inception through March 2024 for articles that reported endoscopic, ultrasound, and nasogastric evaluation for increased residual gastric volume retained food contents, as well as incidences of regurgitation and aspiration events. Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. Results: Of the 3712 citations identified, 24 studies met eligibility criteria. Studies included four prospective, six retrospective, five case series, and nine case reports. The GLP-1 RAs reported in the studies included semaglutide, liraglutide, lixisenatide, dulaglutide, tirzepatide, and exenatide. All studies, except one case report, reported patients with confounding factors for retained gastric contents and aspiration, such as a history of diabetes, cirrhosis, hypothyroidism, psychiatric disorders, gastric reflux, Barrett's esophagus, Parkinson's disease, dysphagia, obstructive sleep apnea, gastric polyps, prior abdominal surgeries, autoimmune diseases, pain, ASA physical status classification, procedural factors (i.e., thyroid surgery associated with risk for nausea, ketamine associated with nausea and secretions), and/or medications associated with delayed gastric emptying (opioids, anticholinergics, antidepressants, beta-blockers, calcium channel blockers, DPP-IV inhibitors, and antacids). Of the eight studies (three prospective and five retrospective) that evaluated residual contents in both GLP-1 users and non-users, seven studies (n = 7/8) reported a significant increase in residual gastric contents in GLP-1 users compared to non-users (19-56% vs. 5-20%). In the three retrospective studies that evaluated for aspiration events, there was no significant difference in aspiration events, with one study reporting aspiration rates of 4.8 cases per 10,000 in GLP-1 RA users compared to 4.6 cases per 10,000 in nonusers and the remaining two studies reporting one aspiration event in the GLP-1 RA user group and none in the non-user group. In one study that evaluated for regurgitation or reflux by esophageal manometry and pH, there was no significant difference in reflux episodes but a reduction in gastric acidity in the GLP-1 RA user group compared to the non-user group. Conclusions: There is significant variability in the findings reported in the studies, and most of these studies include confounding factors that may influence the association between GLP-1 RAs and an increased risk of aspiration and related events. While GLP-1 RAs do increase residual gastric contents in line with their mechanism of action, the currently available data do not suggest a significant increase in aspiration and regurgitation events associated with their use and the withholding of GLP-1 RAs to reduce aspiration and regurgitation events, as is currently recommended by many major societal guidelines. Large randomized controlled trials (RCTs) may be helpful in further elucidating the impact of GLP-1 RAs on perioperative aspiration risk.

Evaluating the Impact of Novel Incretin Therapies on Cardiovascular Outcomes in Type 2 Diabetes: An Early Systematic Review

Background This systematic review is registered with CRD42024507397 protocol number and aims to compare the known data about retatrutide on long-term cardiovascular (CV) protection with tirzepatide, an incretin with recent proven CV benefits. Material and Methods The inclusion criteria were (i) original full-text articles that are randomized control or clinical trials; (ii) published within the last ten years; (iii) published in English; and (iv) conducted on adult human populations. The exclusion criteria were articles deruled on cell cultures or mammals. Studies were selected if they (1) included patients with type 2 diabetes mellitus (DM) and CV risk; (2) patients that received either tirzepatide or retatrutide; and (3) provided sufficient information such as the corresponding 95% confidence intervals or at least a sufficient p-value. Studies were excluded if they were a letter to the editor, expert opinions, case reports, meeting abstracts, or reviews; redundant publications; or needed more precise or complete data. Results The seven included studies were assessed for bias with the Newcastle Ottawa scale, heterogenous, and emphasized the potential CV beneficial effect of type 2 DM (T2DM) therapies (glycemia, glycated A1c hemoglobin, body weight, lipid profile, blood pressure and renal parameter). Discussions Further, longer follow-up studies are necessary to verify the long-term CV protection, standardize the specific aspects of CV risk, and compare with subjects without T2DM for a more integrative interpretation of the CV effects independent of the improvement of metabolic activity.

The Predictive Potential of C-Peptide in Differentiating Type 1 Diabetes From Type 2 Diabetes in an Outpatient Population in Abu Dhabi

PURPOSE

We aimed to investigate the predictive potential of plasma connecting peptide (C-peptide) in differentiating type 1 diabetes (T1D) from type 2 diabetes (T2D) and to inform evidence-based diabetes classification criteria.

METHODS

A retrospective review was performed of all the patients with diabetes visiting an outpatient diabetology, endocrinology, general practice and family medicine tertiary health care center between January 2016 and December 2021.

FINDINGS

Two hundred twelve individuals with diabetes were included, 85 (44.8%) with T1D and 127 (55.2%) with T2D. Mean (SD) age at diagnosis was 35.9 (15.1) years, and 112 (52.8%) men. Median (interquartile range [IQR]) duration of diabetes was 3.8 (3.0-4.5) years (T1D, 3.9 [3.5-4.6]; T2D, 3.4 [2.4-4.4]; P = 0.001). Body mass index was <18.5 kg/m2 in 5 (2.5%) individuals (T1D, 5; T2D, none), 18.5 to <25 kg/m2 in 57 (28.5%) (T1D, 32; T2D, 25), 25 to <30 kg/m2 in 58 (29%) (T1D, 28; T2D, 30), and >30 kg/m2 in 80 (40.0%) (T1D, 20; T2D, 60). Median (IQR) glycosylated hemoglobin was 7.4% (6.7%-8.5%) (T1D, 8.3% [7.2%-9.9%]; T2D, 7% [6.3%-7.6%]; P = 0.0001). Median (IQR) C-peptide concentration was 0.59 nmol/L (0.01-1.14 nmol/L) (T1D, 0.01 nmol/L [0.003-0.05 nmol/L]; T2D, 1.03 nmol/L [0.70-1.44 nmol/L]; P = 0.0001). C-peptide concentration of ≤0.16 nmol/L showed 92.9% sensitivity, 1-specificity of 2.4%, and AUC of 97.2% (CI, 94.7%-99.6%; P = 0.0001) in differentiating T1D from T2D.

IMPLICATIONS

To our knowledge, this is the first study in the Middle East and North Africa region highlighting the role of C-peptide in diabetes classification. The estimated cutoff point for C-peptide concentration (≤0.16 nmol/L) will certainly help in accurately classifying the T1D and will rule out the routine clinical judgmental approaches in the region, especially in those scenarios and periods where it is always difficult to diagnose the diabetes type. Quantifying the cutoff for C-peptide is among the vital strengths of this study that will provide a better treatment plan in diabetes care management. Also, we evaluated concomitant glucose levels to rule out the phenomenon of falsely low C-peptide values in the setting of hypoglycemia or severe glucose toxicity. Based on our findings, C-peptide testing could be included in postulating an evidence-based guideline that differentiates T1D from T2D. Despite this, our study has some limitations, including the selection bias due to the retrospective design and low C-peptide levels could be indicative of low pancreatic reserves due to other causes or long-standing T2D, and quantifying these reasons requires additional resources and time.

Comparison of societal guidance on perioperative management of glucagon-like peptide-1 receptor agonists: implications for clinical practice and future investigations

PURPOSE

The use of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) by patients undergoing surgery and procedures requiring anesthesia has become a topic of significant concern for perioperative providers because of the potential increased risk of aspiration resulting from the medication's effect of delaying gastric emptying. There is currently a lack of high-quality data regarding the safety of GLP-1 RAs in patients undergoing surgery, which has led to variations in practice.

SOURCE

We performed an internet search of society-endorsed statements and guidelines related to perioperative management of GLP-1 RAs, focusing on the top 20 countries with the largest anesthesiology societies determined by membership data from the World Federation of Societies of Anesthesiologists. We excluded articles and websites that were not in English.

PRINCIPAL FINDINGS

Our search revealed endorsed statements from fourteen major anesthesiology, endocrinology, and gastroenterology societies. There was considerable variation between societies in the recommendations and guidance for withholding these medications before surgery, the duration of withholding, assessment of the need for avoiding deep sedation or general anesthesia, use of rapid sequence intubation, need for prolonged fasting periods and clear fluid before a nil per os period, recognition of signs and symptoms for aspiration risk, the management of glucose in the perioperative period, and the use of point-of-care ultrasound for risk assessment.

CONCLUSION

Society-endorsed statements and guidelines provide varying recommendations on the perioperative management of GLP-1 RAs. The insights gained from this comparative analysis may help guide clinical practice, develop institutional practice guidelines, and direct future research efforts.

Mechanistic Pathways and Clinical Implications of GLP-1 Receptor Agonists in Type 1 Diabetes Management

GLP-1 receptor agonists, which were initially intended to treat type 2 diabetes patients, have demonstrated promise as an adjuvant therapy for type 1 diabetes (T1D). These medications can manage T1D by improving β-cell function, reducing glucose fluctuation, and providing cardioprotective effects. Recent research suggests that boosting cell proliferation and lowering apoptosis can help maintain the bulk of β-cells. Furthermore, GLP-1 receptor agonists have potent anti-inflammatory characteristics, improving immunological control and lowering systemic inflammation, both of which are critical for reducing autoimmune damage in T1D. Beyond glucose control, these agonists have neuroprotective qualities and aid in weight management. Combining these medications with insulin could significantly change how T1D is managed. The clinical data and biological mechanisms discussed in this review support the potential use of GLP-1 receptor agonists in T1D.

Beyond Glycemic Control: GLP-1 Receptor Agonists and Their Impact on Calcium Homeostasis in Real-World Patients

Background/Objectives: The effect of glucagon-like peptide-1 receptor (GLP-1R) agonists on calcium homeostasis is poorly understood. This study aimed to investigate the association between GLP-1R agonist use and the risk of hypocalcemia and/or hypercalcemia, as well as other clinical outcomes. Methods: A retrospective cohort study used de-identified patient data from the TriNetX Global Collaborative Network, including 15,655 adult patients prescribed GLP-1R agonists and 15,655 propensity-matched controls. Outcomes included hypocalcemia, hypercalcemia, emergency visits, hospitalizations, cardiovascular events, and all-cause mortality. Results: GLP-1R agonist use was associated with a reduced risk of hypocalcemia (2.7% vs. 5.5%, RR 0.49, 95% CI: 0.44-0.55) but an increased risk of hypercalcemia (2.3% vs. 1.1%, RR 2.02, 95% CI: 1.69-2.42). The effect on hypocalcemia was most pronounced during the first six months of treatment. Among individual agents, tirzepatide showed the most pronounced effect, reducing hypocalcemia risk by 63% while increasing hypercalcemia risk by 85%. Semaglutide demonstrated similar effects, while dulaglutide and liraglutide showed modest effects. Furthermore, GLP-1R agonist use was associated with reduced risks of emergency visits (RR 0.57, 95% CI: 0.54-0.60), hospitalizations (RR 0.40, 95% CI: 0.36-0.44), cardiovascular events, and all-cause mortality (HR 0.27, 95% CI: 0.21-0.36). Conclusions: GLP-1R agonists exhibit a complex influence on calcium homeostasis, reducing hypocalcemia risk while increasing hypercalcemia risk. Beyond calcium regulation, these medications significantly reduce healthcare utilization, improve cardiovascular outcomes, and decrease mortality. Further research is needed to elucidate the mechanisms behind the differential effects of individual GLP-1R agonists, particularly tirzepatide, to optimize personalized treatment approaches and long-term safety.

Rethinking weight loss treatments as cardiovascular medicine in obesity, a comprehensive review

The global escalation of obesity has made it a worldwide health concern, notably as a leading risk factor for cardiovascular disease (CVD). Extensive evidence corroborates its association with a range of cardiac complications, including coronary artery disease, heart failure, and heightened vulnerability to sudden cardiac events. Additionally, obesity contributes to the emergence of other cardiovascular risk factors including dyslipidaemia, type 2 diabetes, hypertension, and sleep disorders, further amplifying the predisposition to CVD. To adequately address CVD in patients with obesity, it is crucial to first understand the pathophysiology underlying this link. We herein explore these intricate mechanisms, including adipose tissue dysfunction, chronic inflammation, immune system dysregulation, and alterations in the gut microbiome.Recent guidelines from the European Society of Cardiology underscore the pivotal role of diagnosing and treating obesity to prevent CVD. However, the intricate relationship between obesity and CVD poses significant challenges in clinical practice: the presence of obesity can impede accurate CVD diagnosis while optimizing the effectiveness of pharmacological treatments or cardiac procedures requires meticulous adjustment, and it is crucial that cardiologists acknowledge the implications of excessive weight while striving to enhance outcomes for the vulnerable population affected by obesity. We, therefore, sought to overcome controversial aspects in the clinical management of heart disease in patients with overweight/obesity and present evidence on cardiometabolic outcomes associated with currently available weight management interventions, with the objective of equipping clinicians with an evidence-based approach to recognize and address CVD risks associated with obesity.

GLP-1 Receptor Agonists and Cardiovascular Disease: What Do Clinicians Need to Know?

PURPOSE OF REVIEW

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are gaining importance due to their effects on cardiovascular parameters. This review discusses the findings of dedicated cardiovascular outcome trials of GLP-1RAs and summarizes their utility to help clinicians understand their role in cardiovascular disease.

RECENT FINDINGS

Patients with diabetes mellitus are at an increased risk of cardiovascular disease. Cardiovascular outcome trials have shown GLP-1RAs decrease the primary composite outcome of the first occurrence of major adverse cardiovascular events (MACE) in patients with diabetes. Additionally, select GLP-1RAs have also shown improved cardiovascular outcomes in patients without diabetes who are either overweight (BMI ≥ 27), or obese (BMI ≥ 30). There have also been encouraging results in patients with heart failure with preserved ejection fraction. There is increasing evidence showing GLP-1RAs are beneficial across the cardiometabolic spectrum of disease. Implementation of these therapeutics into clinical practice is important to improve cardiovascular risk.

Ongoing and Future Clinical Trials of Pharmacotherapy for Heart Failure

Increasing knowledge of the processes leading to heart failure (HF) has allowed significant developments in therapies for HF over the past few decades. Despite the evolution of HF treatment, it still places a large burden on patients and health care systems across the world.We used clinicaltrials.gov to gather information about clinical trials as of August 2023 studying pharmacotherapy for HF. We included interventional trials that were "active, not recruiting", "recruiting", or looking for participants but "not yet recruiting". In total, 119 studies met our criteria of ongoing clinical trials studying novel as well as currently approved HF pharmacotherapies. The major interventions were novel medications/already approved medications for other diseases 29 % (34 trials), sodium-glucose co-transporter inhibitors 21 % (25 trials), angiotensin receptor blocker-neprilysin inhibitors 10 % (12 trials), diuretics 14 % (17 trials) and mineralocorticoid receptor antagonists 5 % (6 trials). Ongoing research will aid in reducing the impact of HF and we summarize clinical trials leading the way to better HF treatment in this review.

Efficacy and safety of albiglutide, a once-weekly glucagon-like peptide-1 receptor agonist, in patients with type 2 diabetes: A systematic review and meta-analysis

BACKGROUND

No meta-analysis has holistically analyzed and summarized the therapeutic efficacy and safety of albiglutide in type 2 diabetes (T2D). This meta-analysis addresses this knowledge gap.

METHODS

Randomized controlled trials involving patients with T2D receiving albiglutide in the intervention arm and either a placebo or an active comparator in the control arm were searched through electronic databases. The primary outcome was the change from baseline (CFB) in glycated hemoglobin (HbA1c); secondary outcomes included CFB in fasting plasma glucose, body weight, and adverse events (AE).

RESULTS

From 443 initially screened articles, data from 12 randomized controlled trials involving 6423 subjects were analyzed. Albiglutide, at both doses, outperformed placebo in terms of HbA1c reductions (for albiglutide 30 mg: mean differences -1.04%, 95% confidence interval [CI] [-1.37--0.72], P < .00001, I2 = 89%; and for albiglutide 50 mg: mean differences -1.10%, 95% CI [-1.45--0.75], P < .00001, I2 = 90%). Higher proportions of subjects achieved HbA1c < 7% in the albiglutide arm than in placebo (for albiglutide 30 mg: odds ratio 6.26, 95% CI [2.50-15.70], P < .0001, I2 = 82%; and for albiglutide 50 mg: odds ratio 5.57, 95% CI [2.25-13.80], P = .0002, I2 = 84%). Albiglutide had glycemic efficacy comparable to other glucose-lowering drugs. CFB in body weight was similar with albiglutide and placebo. AE profile, including gastrointestinal AE, was identical with albiglutide and placebo, except for higher drug-related AE and injection-site reaction with albiglutide.

CONCLUSION

Albiglutide provides reassuring data on good glycemic efficacy, tolerability, and safety over an extended period of clinical use in patients with T2D. Albiglutide 30 mg has comparable efficacy and safety profiles to albiglutide 50 mg.

Liver and cardiovascular disease outcomes in metabolic syndrome and diabetic populations: Bi-directional opportunities to multiply preventive strategies

The incidence and prevalence of metabolic syndrome (MetS) and type 2 diabetes mellitus (T2DM) are rising globally. MetS and T2DM are associated with significant morbidity and mortality, which is partly related to liver and cardiovascular disease. Insulin resistance is central to MetS and T2DM pathophysiology, and drives ectopic fat deposition in the liver, also known as metabolic dysfunction-associated steatotic liver disease (MASLD). MetS and T2DM are not only risk factors for developing MASLD but are also independently associated with disease progression to steatohepatitis, cirrhosis, and hepatocellular carcinoma. In addition to the risk of liver disease, MetS and T2DM are independent risk factors for cardiovascular disease (CVD), including coronary artery disease (CAD) and heart failure (HF). Importantly, there is a bidirectional relationship between liver and CVD due to shared disease pathophysiology in patients with MetS and T2DM. In this review, we have described studies exploring the relationship of MetS and T2DM with MASLD and CVD, independently. Following this we discuss studies evaluating the interplay between liver and cardiovascular risk as well as pragmatic risk mitigation strategies in this patient population.