Should metformin still be the first-line of treatment in type 2 diabetes mellitus? A comprehensive review and suggested algorithm.

For more than a century, the high occurrences of coronary and peripheral artery diseases in diabetes mellitus patients has been well recognised; despite that, the ability to improve CV event rates by optimizing glycaemic control has remained elusive. Nevertheless, the last decade has seen several cardiovascular outcome clinical trials (CVOTs) of many antihyperglycemic agents that reported promising results for cardiovascular and renal outcomes. This leads to a hot debate on the ideal drug choice for first-line treatment in T2DM. The purpose of this paper is to review the evidence supporting the use of metformin, sodium-glucose cotransporter 2 (SGLT2) inhibitors and incretin-based therapies for the management of individuals with T2DM and, discuss the rationale for selection.

Impact of optimum diabetes care on the safety of fasting in Ramadan in adult patients with type 2 diabetes mellitus on insulin therapy.

AIM: We aimed at evaluating the safety of fasting Ramadan for insulin treated type 2 diabetes patients by assessing the biochemical, biometric parameters, flash glucose monitoring (FGM) data as compared to pre-Ramadan and hospital admissions with diabetes or non-diabetes conditions. The risks of fasting between those treated with basal insulin vs intensive insulin during Ramadan was also assessed. METHODS: We included insulin treated patients with type 2 diabetes and we excluded those with co-morbidities. Patients were provided with Ramadan-focused education, FGM before and during Ramadan and medical advice for treatment adjustment. We measured biologic and biometric data before and after Ramadan. RESULTS: HbA1c reduced from 7.9 ±â€¯1.20 pre-Ramadan to 7.7 ±â€¯1.5% post Ramadan (p = 0.023). Average peak glucose reading was 330.1 ±â€¯79.8 mg/dl before Ramadan improved significantly to reach 289.3 ±â€¯77.7 mg/dl (p = 0.013). Average number of hypoglycemic episodes was higher in intensive insulin group between 1200 and 1800 h (p = 0.028). CONCLUSION: People with type 2 diabetes treated with insulin who fast Ramadan and who are provided with Ramadan focused patient education, individualized treatment adjustment and FGMS were not at increased safety risks as measured by biochemical, biometric and FGM data.

A prospective multi-country observational trial to compare the incidences of diabetic ketoacidosis in the month of Ramadan, the preceding month, and the following month (DKAR international).

BACKGROUND: 1.7 billion Muslims worldwide obey divine commands of fasting for a month. This may increase the probability of the acute complications of diabetes during the fasting period. DESIGN AND METHODS: We primarily aimed to compare the incidences and duration of Diabetic ketoacidosis (DKA) admissions during Ramadan compared to the month before (Shaaban) and the month after (Shawal) as well as the average pre-Ramadan six months' admissions. Our secondary objective was to assess the different incidence of DKA between Ramadan and the other months regarding precipitating factors, fasting practices in people admitted with DKA and gender differences. This was a prospective study that included all Muslims who were admitted with DKA to major hospitals in the United Arab Emirates, Sudan, Tunisia and Morocco during the pre-Ramadan month, Ramadan and post-Ramadan month, in addition to the average monthly admissions during the last six months before Ramadan. Demographics, clinical, and laboratory indices were collected and analyzed to assess primary and secondary end points. RESULTS: One hundred seventy patients were admitted during the study duration, 56 were admitted during Ramadan and 63 in Shawal. Six months before Ramadan showed an average admission of 56 + 7 per month. All those admitted during Ramadan were people with type1 diabetes. 29.8 % of those admitted during Ramadan did not receive structured education program on diabetes management in Ramadan. Non-compliance to medications represented the commonest cause for admission in the whole study period. Hospital stay was comparable through different months, but the duration of acidosis was longest during Ramadan month. CONCLUSION: In concordance with DKAR1, DKAR international showed higher rates of DKA during Ramadan when compared to preceding Lunar month (Shaaban). In Shawal, however, the rates of DKA admission were higher than the average monthly DKA admissions. The duration of acidosis was longer in Ramadan group and positively correlated with duration of diabetes. Many patients did not receive structured education about diabetes and fasting Ramadan. Our study calls for formal pre-Ramadan education and enforces the need for advice against fasting in patients who already experienced DKA in the months preceding Ramadan.

Liraglutide effect in reducing HbA1c and weight in Arab population with type2 diabetes, a prospective observational trial.

BACKGROUND: The pathophysiology of type2 diabetes differs between different ethnic groups. Asians develop type2 diabetes at younger age, lower body mass index, and in relatively short time. Not only that, some ethnicities have different responses and dosing regimens to different classes of anti-diabetic agents. Data from Japanese population showed that the optimal doses of liraglutide used are smaller than other population and that weight loss is not as effective as seen in Caucasians. METHODS: We aimed to assess liraglutide efficacy in reducing weight and HbA1c in Arab population when used as add on to other anti-diabetic agents. We prospectively followed patients who were recruited to treatment with liraglutide for a 6 months period; at the start of the study we checked patients' demographics, weight, blood pressure, fasting blood glucose, HbA1c, lipid panel, LFTs and creatinine. Patients were checked at 3 months and at the end of the study at 6 months. RESULTS: There was a significant reduction in weight at 3 and 6 months from a mean weight of 96.01 ± 19.2 kg to (94.8 ± 20 kg with (P < 0.001)) and 94.5 ± 19 kg with (p < 0.001) respectively. Mean HbA1c at baseline was 8.3 ± 1.7 % dropped to 7.7 ± 1.4 % (p < 0.001) at 3 months, and 7.6 + 1.6 % (p < 0.001) at 6 months. CONCLUSIONS: Liraglutide is effective in reducing weight, HbA1c as well as other metabolic parameters in Arab population with type2 diabetes. TRIAL REGISTRATION: The trial is approved and registered with the Institutional Ethical Committee Board (Dubai Health Authority Medical Research Committee) under registration Number (MRC-08/2013_03).

Exenatide's effect in reducing weight and glycosylated hemoglobin level in an Arab population with type 2 diabetes.

OBJECTIVES: To determine whether exenatide is effective in reducing weight and glycosylated hemoglobin level (HbA1c), and to investigate its efficacy in improving lipid profile, blood pressure, and creatinine levels in the Arab population. METHODS: This study was conducted at the Endocrine Unit, Dubai Hospital, Dubai, United Arab Emirates. We retrospectively collected data from patients with type 2 diabetes started on exenatide between November 2011 and February 2012. Data included demographics, clinical, laboratory results, and medications used. A general linear model adjusted by baseline characteristics (weight, HbA1C, age, use of statins, and duration of diabetes) was used to assess changes between baseline and end of trial in HbA1C, weight, low density lipoprotein cholesterol, total cholesterol, triglycerides, creatinine, and blood pressure. RESULTS: After 6 months of treatment with exenatide, the HbA1c decreased by 0.47% (95% confidence level [CI]: -0.01 - 0.95) (p=0.055). Weight reduction was highly significant; 5.6 kg (95% CI: 3.34 - 7.85) (p<0.001). Those reductions remained significant after adjustment for confounding factors. CONCLUSION: This study showed that weight reduction was highly significant with exenatide. The borderline significance in HbA1c reduction can be attributed to the small sample size.