Study of the Efficacy of Uptitrating Teneligliptin Dose from Standard Dose (20 mg) to High Dose (40 mg) in Patients with Type II Diabetes Mellitus

AIM

To study the efficacy of uptitrating the dose of Teneligliptin from 20 to 40 mg in patients with type II diabetes mellitus.

METHOD

A retrospective, comparative analysis was undertaken in 853 type II diabetes mellitus patients (499 males and 354 females) who had follow-up records for more than 6 months. These patients were uncontrolled after use of atleast three oral antidiabetic drugs (OADs) and Teneligliptin 20 mg was added as the fourth drug. Patients who remained uncontrolled with the addition of 20 mg of Teneligliptin at the end of 3 months and were switched to receive 40 mg of Teneligliptin daily were included in this study. Results were analyzed at 3 and 6 months to ascertain efficacy of high-dose (40 mg) Teneligliptin. All other OADs remained the same in both groups. In all patients, the fasting blood glucose, postprandial blood glucose, and hemoglobin A1c (HbA1C) were evaluated and compared.

RESULT

A total of 853 patients whose dose of Teneligliptin was increased from 20 to 40 mg were included in the study. At the end of 3 months after using Teneligliptin 40 mg, mean reduction in HbA1C was 0.5% (p-value 0.154). Similarly, mean reduction in fasting blood sugar (FBS) and postprandial blood sugar (PPBS) was 6.5 and 3.6 mg/dL, respectively (p-value 0.234 and 0.143). At the end of 6 months after using Teneligliptin 40 mg HbA1C showed no change but mean FBS and PPBS showed a modest reduction of 14.6 and 14 mg/dL, respectively (p-value < 0.001).

CONCLUSION

The results of our study show that there was no statistically significant improvement in glycemic parameters when dose of Teneligliptin was increased from 20 to 40 mg at 3 months. But at 6 months, the FBS and PPBS showed a modest reduction of 14.6 and 14 mg/dL, respectively (p-value < 0.001) but the HbA1C showed no change.

Teneligliptin Real-World Effectiveness Assessment in Patients with Type 2 Diabetes Mellitus in India: A Retrospective Analysis (TREAT-INDIA 2)

INTRODUCTION

Teneligliptin is an antidiabetic medication that has been approved for the management of type 2 diabetes mellitus (T2DM) in Japan, South Korea and India. It is one of the most commonly prescribed antihyperglycaemic agents. The aim of this study was to assess the effectiveness of teneligliptin in improving glycemic control amongst Indian patients with T2DM in a real-world setting.

METHODS

This was a retrospective observational study in which a predesigned structured proforma was used to collect information from hospital records of 18 medical centres across India. All participating centres were established primary care hospitals with adequate record keeping, a pre-determined condition in the study design. Data were collected during the period of January 2019 to June 2019. Data extracted from patient records, including glycaemic parameters, concomitant drugs, drug dosage and duration, were collated. The effectiveness of teneligliptin was assessed by analyzing the mean change in glycosylated haemoglobin (HbA1c), fasting plasma glucose (FPG) and post-prandial plasma glucose (PPG) at 12 weeks after initiation of teneligliptin.

RESULTS

Data from 10,623 patients were available for analysis. The mean age of the enrolled patients was 51.86 ± 11.76 years. At 12 weeks after initiation of teneligliptin as monotherapy or add-on to other medications (combination therapy), the patients showed a signficant decrease from baseline in mean HbA1c, FPG and PPG. Mean HbA1c dropped from 8.66 ± 1.15% at baseline to 7.67 ± 1.28% at 12 weeks (71 ± 12.6 to 60 ± 14 mmol/mol), with a difference of - 0.99% (95% confidence interval [CI] 0.96-1.02) or - 10.8 (95% CI 10.5-11.1) mmol/mol (p < 0.0001). The mean reductions in FPG and PPG were 43.12 mg/dL (2.39 mmol/L) and 87.73 mg/dL (4.87 mmol/L) (both p < 0.0001) respectively. HbA1c (%) reductions with teneligliptin when used as add-on to metformin, add-on to metformin + sulfonylurea combination and add-on to metformin + sulfonylurea + alpha glucosidase inhibitor combination were 0.76% (8.3 mmol/mol), 1.24% (13.6 mmol/mol) and 1.04% (11.4 mmol/mol), respectively. Teneligliptin also significantly reduced HbA1c (1.13% or 12.4 mmol/mol, p < 0.0001) in patients with impaired renal function, without worsening the estimated glomerular filtration rate. Teneligliptin consistently reduced HbA1c across all three age categories tested-by 1% (10.9 mmol/mol) in patients aged < 60 years, by 1.15% (12.6 mmol/mol) in patients aged 60-75 years and by 0.88% (9.6 mmol/mol) in patients aged > 75 years.

CONCLUSION

Teneligliptin significantly improved glycaemic parameters in Indian patients with T2DM when prescribed either as monotherapy or as an add-on to one or more other commonly prescribed antihyperglycaemic agents.

Efficacy of DPP4i as the Fourth Drug in the Management of Type2 Diabetes Mellitus in Asian Indians Poorly Controlled by Use of at least 3 Oral Antidiabetic Drugs

AIM

To evaluate the efficacy of DPP-4 inhibitors (DPP-4i) as the fourth drug in Asian Indian type2 DM patients uncontrolled inspite of using at least 3 oral anti diabetic drugs.

METHODS

A retrospective analysis of 7858 T2DM patients, who received a DPP-4i (Sitagliptin, Vildagliptin, Teneligliptin, Linagliptin and Saxagliptin) as the fourth drug to achieve glycemic control was undertaken. Patients with inadequate glycaemic control despite receiving optimum doses of at least any other three OADs were included in this analysis.

RESULTS

Patients were subdivided into 5 groups, based on the DPP-4i used for treatment: Sitagliptin (n=4787), Vildagliptin (n=2205), Teneligliptin (n=775), Linagliptin (n=64) and Saxagliptin (n=27). The mean fasting blood glucose (FPG) was 160.9 ± 20.4 mg/dl and mean post prandial glucose (PPG) was 227.8 ± 26.3 mg/dl. The mean baseline HbA1c was 8.2 ± 1.5 %. The mean duration required to control diabetes with all DPP-4i was 8.2 weeks with significantly lesser time with Sitagliptin (6.8 weeks, p<0.001). 81.5% of the total cases responded to treatment with a DPP-4i (P <0.05). At the end of the monitoring period, there was significant reduction in mean FPG by-28.1 ± 16.1 mg/dL(P=0.001), mean PPG by -55.3 ± 17.0 mg/dL(P=0.001), and mean HbA1c by -1.2 ± 0.7 (P= 0.001). There was no significant difference between the groups with respect to reduction in PPG and HbA1c.

CONCLUSION

DPP-4 inhibitors are effective in achieving desired glycaemic goals even when used as a fourth drug in patients with inadequate glycaemic control despite receiving an optimum dose of at least 3 OADs.

Efficacy of SGLT2 Inhibitors as the Fifth Drug in the Management of Type 2 Diabetes Mellitus in Asian Indians not Controlled with at least 4 Oral Antidiabetic Drugs

AIM

To evaluate the efficacy of SGLT2 inhibitors as an add-on therapy along with stricter lifestyle modification in Asian Indian type 2 diabetes mellitus (T2DM) patients with inadequate glycemic control despite receiving an optimum dose of at least 4 oral antidiabetic drugs (OADs).

METHODOLOGY

A retrospective analysis of data of 808 T2DM patients being treated with an SGLT2 inhibitor (Dapagliflozin, Empagliflozin or Canagliflozin) as an add-on drug in patients with inadequate glycemic control despite receiving optimum doses of at least any four OADs(metformin, sulphonylureas, pioglitazone, DPP4 Inhibitors, alpha-Glucosidase Inhibitors) and who preferred not to initiate insulin.

RESULTS

The average age of the patients included was 51.63 years (SD ± 9.88). 57.7% were males. Average weight was 81.95±16.08 kg. Mean duration of diabetes was 34.08±39.04 months. The mean baseline fasting plasma glucose was 198.21 ± 38.21 mg/dl and mean post prandial plasma glucose was 264.22 ± 45.22 mg/ dl. The baseline HbA1c was 8.92 ± 1.47 %. Total 87.4 % of the cases responded to addition of SGLT2 inhibitors during a mean follow-up period of 6 months. The fasting plasma glucose (FBS) was reduced by -63.65 ± 19.93 mg/dl to a mean FBS of 134.57 ± 33.65 mg/dl (P=0.001). The post prandial plasma glucose (PPBS) was reduced by -79.28 ± 23.57 mg/dl to a mean PPBS of 184.94 ± 38.34 mg/dl (P=0.001). The mean HbA1c reduced significantly by -1.63 ± 0.99 % (P= 0.001). The mean weight reduction at 6 months of therapy was -3.03± 01.84 kg that is 3.8 % decrease from baseline (p=0.001).The response in age group < 55 years was 90.9 %, whereas in ≥55 years, it was 82.2% (p=0.001). The males responded more (91.0%) compared to females (82.5%) (p=0.001). Those with BMI < 23.5 kg/ m2 had marginally higher but insignificant response of 93.0% as compared to 87.1% in patients with high a BMI (≥23.5 kg/m2) (p=0.253). Patients with < 5years duration of diabetes responded better (91.8%) as compared to patients with a ≥ 5 years of diabetes (85.4%).

CONCLUSION

SGLT2 inhibitors are effective in achieving desired glycemic goals even when used as a fifth add-on drug along with strict lifestyle modification in patients with inadequate glycemic control despite receiving an optimum dose of at least 4 oral antidiabetic drugs (OADs). SGLT2 inhibitors can be effectively used at any stage of diabetes.

Autoimmune Hypoglycemia Relapse on Glucocorticoids, Effectively Treated with Azathioprine

Autoimmune Hypoglycemia, though very rare in India, but can be challenging to manage. Insulin autoimmune syndrome (IAS) should be considered in any patient with hypoglycemia in the setting of unsuppressed insulin levels associated with anti-insulin or anti insulin receptor antibodies. We are reporting the clinical course of one such case of insulin autoimmune syndrome, who was initially treated with glucocorticoids. The patient relapsed and was later on treated effectively with Azathioprine for glucocorticoids failure and toxicity.

Effect of Low (7.5 mg/day), Standard (15 mg/ day) and High (30 mg/day) Dose Pioglitazone Therapy on Glycemic Control and Weight Gain in Recently-Diagnosed Type 2 Diabetes Patients

OBJECTIVE

To study the effect of different daily doses of pioglitazone on glycemic control and weight gain in newly-diagnosed type 2 diabetes mellitus (DM) patients.

RESEARCH DESIGN AND METHODS

Chart reviews were performed of recently-diagnosed (<24 months) type 2 DM patients receiving oral therapy including pioglitazone. Patients were excluded if they had heart disease, liver dysfunction or renal insufficiency; or were being treated with insulin or the incretin drugs. Patients had received 7.5 mg/day (Group A), 15 mg/day (Group B) or 30 mg/day (Group C) of pioglitazone. Characteristics including demographics, weight, body mass index and glycated hemoglobin (HbA1c) were recorded at baseline and at six months.

RESULTS

At the end of six months, there was significant weight gain in all groups from baseline (P<0.01). Weight gain was greatest in Group C (2.72 kg; SD=2.97), intermediate in Group B (1.62 kg; SD=2.91) and least in Group A (0.88 kg; SD=2.77). The difference was statistically significant between Groups A and C; and Groups B and C; but not between Groups A and B. There was no difference between HbA1c lowering in the three groups (P>0.05). Dose correlated with weight gain (r=0.254; P<0.001) but not with HbA1c reduction (r=0.012; P=0.85). There was no correlation between HbA1c reduction and BMI increase (r = -0.024; P=0.72).

CONCLUSIONS

The glycemic effect of pioglitazone is preserved even at lower doses, while the propensity to cause weight gain increases with dose. We suggest that low-dose pioglitazone (7.5 mg/day) should be the preferred dose at which to initiate therapy in recently-diagnosed patients. Pioglitazone is an extremely useful agent in the treatment of type 2 diabetes mellitus (DM) through its actions on alleviating insulin resistance.

Hyperammonemic coma presenting as Hashimoto's encephalopathy

Hyperammonemia is commonly encountered in active liver disease. Evaluation of patients having hyperammonemia with normal liver function is difficult. We present a case referred to us as undiagnosed hyperammonemic coma with normal liver function, who was subsequently diagnosed to have Hashimoto's encephalopathy. In patients with hyperammonemia without hepatic dysfunction, one must search for the presence of hypothyroidism. Hashimoto's encephalopathy though described to be rare in literature, is often underlooked. In patients with undiagnosed coma, one must look for it as it is easy to diagnose and treat.

Prevalence of metabolic syndrome in an urban Indian diabetic population using the NCEP ATP III guidelines

OBJECTIVE

To study the prevalence of metabolic syndrome (MetS) in an urban Indian diabetic population.

RESEARCH DESIGN AND METHODS

A total of 5088 type 2 diabetes patients (2908 men and 2180 women) presenting to endocrinology clinics at four centers across Mumbai (a large metropolitan city in India) were selected for the study. Anthropometric (waist circumference), clinical (blood pressure) and biochemical (serum triglycerides, HDL, fasting and post-prandial blood glucose) data were recorded. Patients receiving treatment for hypertension or dyslipidemia were also included in the study and these were considered in the diagnosis of MetS even if the parameters were normal. The National Cholesterol Education Program Adult Treatment Panel III guidelines were used to diagnose MetS. The chi-square test was used to determine statistical significance, which was taken as a p value < 0.05.

RESULTS

The prevalence of MetS among urban Indian diabetic patients was 77.2% and was significantly higher in women (87.71%) as compared to men (69.33%) (p < 0.0001). The most prevalent risk factors for MetS were hypertension, followed by hypertriglyceridemia, in men, and central obesity, followed by hypertension, min women.

CONCLUSIONS

MetS is highly prevalent in the urban Indian diabetic population. It should be identified by regular screening in individuals from the general population to avert or delay the progression to type 2 diabetes in order to reduce diabetes-related morbidity and mortality.

Induction of long-term glycemic control in type 2 diabetic patients using pioglitazone and metformin combination

AIMS AND OBJECTIVE

To study the effects of pioglitazone and metformin combination in type 2 diabetics in achieving long-term optimal glycemic control.

METHODS AND MATERIALS

Patients whose duration of type 2 diabetes was less than 24 months were selected for the study. 373 such patients meeting the selection criteria were included in the study and were started on triple drug combination therapy.

RESULTS

Three hundred seventy three (183 females and 190 males) patients were initiated on a triple drug combination of gliclazide 80 mg, tid, metformin 500 mg tid and pioglitazone 30 mg od. Once controlled, the doses of gliclazide were reduced if the blood glucose levels decreased. Those patients whose plasma glucose remained in the normal range for more than 6 months without the use of a sulphonylurea were considered to be in pharmacological remission. 48 patients were lost to follow up. At the beginning of the study the pre treatment biochemical parameters in these 325 diabetic patients at the time of enrolment were: average FBG of 209.44+/-73.82 mg/dl, PLBG 294.96+/-107.58 mg/dl, and HbA(1c) 11.21+/-3.85. The post treatment glycemic parameters were: FBG was 124.38+/-40.48 mg/dl (p < 0.0001), and PLBG 162.32+/-54.33 mg/dl (p < 0.001), average glycosylated hemoglobin was 6.45+/-2.17 (p < 0.001). After using the triple drug combination pharmacological remission was achieved in 36.3 percent i.e. 118 (60 males and 58 females) patients. The average time required for achieving remission was 4 (+/-3.3) months in males and 5 (+/-4.02) months in females. 118 patients were maintained remission after 2 years of follow up. The average duration of remission is 27 (+/-2.66) months. There was an average weight gain of 2.56 +/- 1.32 kg in both the groups of patients in remission and those who could not achieve remission.

CONCLUSIONS

In this study we have found that we could achieve long term glycemic control 'pharmacological remission' in 118 of the 325 patients i.e.36% of type 2 diabetic patients. Insulin sensitizers like pioglitazone along with metformin may induce long-term glycemic control in type 2 diabetic patients.

Beneficial effects of triple drug combination of pioglitazone with glibenclamide and metformin in type 2 diabetes mellitus patients on insulin therapy

BACKGROUND

The thiazolidinediones are a class of antidiabetes medication that enhance the actions of insulin in muscle, liver, and adipose tissue. Data have been lacking on their use in combination with both sulfonylurea and metformin among patients of type 2 diabetes who are on insulin therapy secondary to failure of routine oral hypoglycemic drugs in controlling their diabetes.

OBJECTIVE

To determine the effects of pioglitazone in combination with sulphonylurea and metformin on diabetes control in patients being treated with insulin due to secondary failure of oral hypoglycemic agents.

PATIENTS

One hundred and twenty-four consecutive type 2 diabetes patients (mean age, 57.13 years) attending four centres in Mumbai, who were being treated with insulin were selected. They were switched on to triple drug combination of glibenclamide 5 mg, metformin 500 mg and pioglitazone 15 mg along with insulin. Study participants were required to have type 2 diabetes mellitus for atleast 5 years. Patients were excluded if they had any of the following: serum creatinine concentration greater than 1.5 mg/dl, alanine aminotransferase (ALT) level more than two times the upper limit of normal, symptomatic angina, cardiac insufficiency or history of myocardial infarction.

RESULTS

Pioglitazone 15 mg with glibenclamide 5 mg and metformin 500 mg, significantly decreased hemoglobin HbA1c level from 11.5% to 7.32% (P < 0.001), average fasting blood glucose from 194.8 mg/ dl to 124.06 mg/dl (p < 0.01), average post-prandial blood glucose from 256.24 to 162.32 mg/dl (p < 0.01). At 6 months, 43.35% of patients did not need to be continued on insulin. The total insulin requirement in 124 patients reduced by 71.81%. There were no significant side effects, liver enzymes were within acceptable levels, average weight gain was 2.23 kg, significant hypoglycemia was observed in 28 patients with two requiring hospitalisation, these patients were those who did not stick to follow-up schedules.

CONCLUSIONS

With proper patient selection, pioglitazone with glibenclamide and metformin can be safely used in patients receiving insulin with good results.