Are All Type 2 Diabetes Medications Created Equal?
Daniel D. Dressler, MD, MSc, MHM, FACP reviewing Tsapas A et al. Ann Intern Med 2020 Jun 30
For high-risk patients, some drug classes should be considered preferentially to lower risk for mortality and other adverse outcomes.
Many therapeutic options exist for patients with type 2 diabetes, but we have few head-to-head trials in which newer glucose-lowering medications have been compared with each other and with older agents to guide clinical decision making. Now, researchers have compared the efficacy and safety of 21 antidiabetic agents (in 9 drug classes) with one another (and with placebos) in a meta-analysis that included 450 randomized trials and more than 320,000 patients.
Results were as follows:
- Among treatment-naive patients with low cardiovascular (CV) risk, all drugs and drug classes had similar efficacy in lowering glycosylated hemoglobin (HbA1c) except for dipeptidyl peptidase-4 (DPP-4) inhibitors, which were less effective in glucose-lowering.
- Among all patients with low CV risk, no regimen differed from placebo in vascular or mortality outcomes.
- Among patients with high CV risk who received metformin therapy, all-cause mortality was significantly lowered by adding specific glucagon-like peptide-1 (GLP-1) agonists (i.e., exenatide, liraglutide, or semaglutide) or specific sodium-glucose cotransporter-2 (SGLT-2) inhibitors (i.e., dapagliflozin or empagliflozin). Risk for stroke was significantly lowered by adding specific GLP-1 agonists (i.e., dulaglutide or semaglutide); heart failure hospitalizations and end-stage renal disease were significantly lowered by adding SGLT-2 inhibitors.
COMMENT
Consistent with results of prior analyses, patients with low CV risk gain HbA1c-lowering benefit from most glucose-lowering agents, and metformin should remain the first-line option due to its low cost and low side-effect profile. For patients with high CV risk who receive metformin-based therapy, some SGLT-2 inhibitors and GLP-1 agonists offer significant improvement in mortality and other outcomes and should be considered preferentially as add-on therapy. However, these new drugs are extremely expensive, and numbers needed to treat to prevent one adverse event are high.
Metformin. Glargine. Exenatide. Flozin. But I wonder whether there would be CV and Renal protection if the Lifestyle does not bring the Blood Sugar down?
For developing world: Metformin. Insulin. Lifestyle. All other medications are beyond the purchasing power of most patients. We have to train Lifestyle coaches and Nutritionists and patient advocates. Medications account for 25% of the control of Type 2 Diabetes. 1/3 of the patients regardless of where they live: Beirut, Kabul or Cambodia will have A1c of 7.0.
TO PROBIOTICS OR NOT
july 7, 2020
Probiotics to Reduce Antibiotic Use in Nursing Home Patients?
Thomas L. Schwenk, MD reviewing
In a randomized trial, probiotics conferred no benefits.
Probiotics are used widely for a range of purported benefits, including reduction of antibiotic use through various proposed mechanisms. In this randomized trial, researchers examined whether probiotics reduced antibiotic administration in 310 nursing home patients (mean age, 85) in the U.K. Each patient received a daily probiotic capsule containing Lactobacillus rhamnosus GG and Bifidobacterium animalis lactis BB-12 (≈10 billion cells in each capsule) or a matching placebo capsule. Patients who already were taking probiotics, or who were immunocompromised, were excluded.
During mean follow-up of ≈8 months, during which roughly one fifth of patients died, researchers found no significant difference between the two groups in the number of days of receiving antibiotics for all causes (mean, 12.9 days for intervention patients vs. 12.0 days for control patients). Antibiotic use for lower respiratory infections was significantly shorter in control patients than in intervention patients (4.0 vs. 6.2 days), but no difference was found for several other clinical conditions. Adverse events, hospitalizations, quality of life, antibiotic-associated diarrhea, and other secondary measures were not significantly different between groups.
COMMENT
These results, showing no reduction in antibiotic use and no benefit for other measures, do not support the practice of probiotic use in nursing home patients.
Israel leads the world in Microbiome and Pro/Pre Biotic research. They have repeatedly shown that uncontrolled use of ProBiotics actually do harm. Await more work on this field. That has not stopped Americans and Westerners and some Asians spending money on Probiotics. There is an effect called Placebo Effect, so good luck to them.
STATIN STATIN STATIN what a great Sin not to put them on ?
uly 7, 2020
Statins for Primary CV Prevention in Older Adults
Thomas L. Schwenk, MD reviewing
In a retrospective study, initiating statins in older patients was associated with lower mortality during 7 years of follow-up.
The relatively small number of older adults who have been enrolled in prior randomized, controlled trials (RCTs) of statins has led to uncertainty regarding their value in primary prevention of atherosclerotic cardiovascular disease. Investigators used the Veterans Health Affairs database to perform a retrospective cohort study of about 327,000 patients (age, ≥75; mean age, 81; mostly white men) without prior statin use; about 57,000 received new statin prescriptions during mean follow-up of 7 years. Patients with any form of cardiovascular disease at baseline and those who died within 150 days of enrollment were excluded. Patients with cancer, dementia, or paralysis were not excluded.
Crude cardiovascular-related mortality for statin users and nonusers was 22.6 and 25.7 per 1000 person-years, respectively. Corresponding all-cause mortality was 78.7 and 98.2 per 1000 person-years. In analyses adjusted for a wide range of clinical and demographic variables, statin initiation was associated with significantly lower cardiovascular-related and all-cause mortality (hazard ratios, 0.80 and 0.75, respectively).
COMMENT
Despite its retrospective nature, this study benefited from a large national database, robust adjustment, and inclusion of patients with underlying severe noncardiovascular conditions. Based on these results, some clinicians might decide to initiate statins for primary prevention in patients older than 75. However, at least some residual confounding is likely in this retrospective study, and other clinicians might prefer to wait until ongoing RCTs of statins for primary prevention in older patients are completed.
I personally think STATINs are great medications but I firmly believe that they do what they are supposed to do Lower Cholesterol. In fact, in our patients I check, on those on Statin, their TC and LDL cholesterol, if they are down, you know that they are taking Statins and as a logical extension, the other medications in their med-boxes.
In 2005, I was thinking why there had been an explosion of Hypercholesterolemia in the USA and in the western world to a lesser degree. The higher degrees of Cholesterol, could they indicate an INFLAMMATORY state of the body ? and that Statins are a wonderful anti-metbolic inflammatory preparation ?
Here is a review published in 2017
Curr Cardiol Rev. 2017 Aug; 13(3): 209–216.
Published online 2017 Aug. doi: 10.2174/1573403X13666170426104611
The Anti-Inflammatory Effects of Statins on Coronary Artery Disease: An Updated Review of the Literature
Evangelos Diamantis,* George Kyriakos, Lourdes Victoria Quiles-Sanchez, Paraskevi Farmaki, and Theodoros Troupis
Background:
Statins have long been used for the protection against coronary artery disease (CAD). Their beneficial effect apart from cholesterol reduction lies in their pleiotropic properties. Emerging evidence from laboratory studies and clinical trials as well have pointed out the pivotal role of inflammation on the initiation and exacerbation of atherosclerosis; a major cause of CAD. Inflam-mation markers such as high sensitivity C-reactive protein and adhesion molecules are shown to in-crease in CAD patients and are used as prognostic tools. It is well known that statins can actually re-duce the circulating levels of these agents slowing therefore the inflammatory process; interestingly not all types have the same outcome.
