Combination therapy with once-weekly glucagon like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes: a case series

BACKGROUND: National treatment guidelines recommend glucagon-like peptide receptor agonists (GLP-1 RAs) as add-on therapy to oral agents. However, GLP-1 RAs in combination with dipeptidyl peptidase-4 (DPP-4) inhibitors is not recommended due to a lack of evidence. OBJECTIVE: This case series aims to describe the efficacy and safety of once-weekly GLP-1 RAs administered concomitantly with DPP-4 inhibitors in patients with type 2 diabetes. METHODS: A retrospective chart review of electronic medical records at a free health clinic was conducted between July 2014 and September 2016. Patients 18 years and older with type 2 diabetes were included if they received concomitant DPP-4 inhibitor and once-weekly GLP-1 RA therapy with at least one glycated hemoglobin A1c (HbA1c) measurement within three to six months of starting the combination. The primary and secondary outcomes included change in HbA1c and weight, and patient reported adverse events. RESULTS: Out of forty-three patients that received combination DPP-4 inhibitor plus GLP-1 RA therapy, only eighteen received once-weekly GLP-1 RA. At 3 months, the median (IQR) HbA1c and weight change was -0.8% (-4.3 to 2%) and -0.4kg (-4.2 to 5.8 kg) respectively. No patients reached an HbA1c below 7% and only three patients (17%) reached a HbA1c less than 8%. Patient reported adverse effects included gastrointestinal disturbances (28%), hypoglycemic symptoms (17%), and injection site reactions (0.6%). CONCLUSIONS: Concomitant use of once-weekly GLP-1 RAs and DPP-4 inhibitors provides only modest improvement in glycemic control with minimal weight loss benefits, which is similar to monotherapy with either agent. The combination is unlikely to provide synergistic effects and is not cost effective. These data support the current recommendations against use of combined incretin therapy

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Combination therapy with once-weekly glucagon like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes: a case series.

BACKGROUND: National treatment guidelines recommend glucagon-like peptide receptor agonists (GLP-1 RAs) as add-on therapy to oral agents. However, GLP-1 RAs in combination with dipeptidyl peptidase-4 (DPP-4) inhibitors is not recommended due to a lack of evidence. OBJECTIVE: This case series aims to describe the efficacy and safety of once-weekly GLP-1 RAs administered concomitantly with DPP-4 inhibitors in patients with type 2 diabetes. METHODS: A retrospective chart review of electronic medical records at a free health clinic was conducted between July 2014 and September 2016. Patients 18 years and older with type 2 diabetes were included if they received concomitant DPP-4 inhibitor and once-weekly GLP-1 RA therapy with at least one glycated hemoglobin A1c (HbA1c) measurement within three to six months of starting the combination. The primary and secondary outcomes included change in HbA1c and weight, and patient reported adverse events. RESULTS: Out of forty-three patients that received combination DPP-4 inhibitor plus GLP-1 RA therapy, only eighteen received once-weekly GLP-1 RA. At 3 months, the median (IQR) HbA1c and weight change was -0.8% (-4.3 to 2%) and -0.4kg (-4.2 to 5.8 kg) respectively. No patients reached an HbA1c below 7% and only three patients (17%) reached a HbA1c less than 8%. Patient reported adverse effects included gastrointestinal disturbances (28%), hypoglycemic symptoms (17%), and injection site reactions (0.6%). CONCLUSIONS: Concomitant use of once-weekly GLP-1 RAs and DPP-4 inhibitors provides only modest improvement in glycemic control with minimal weight loss benefits, which is similar to monotherapy with either agent. The combination is unlikely to provide synergistic effects and is not cost effective. These data support the current recommendations against use of combined incretin therapy.

77Se NMR spectroscopic, DFT MO, and VBT investigations of the reversible dissociation of solid (Se6I2)[AsF6]2.2SO2 in Liquid SO2 to solutions containing 1,4-Se6I2(2+) in equilibrium with Se(n)2+ (n = 4, 8, 10) and seven binary selenium iodine cations: preliminary evidence for 1,1,4,4-Se4Br4(2+) and cyclo-Se7Br+.

The composition of a complex equilibrium mixture formed upon dissolution of (Se(6)I(2))[AsF(6)](2).2SO(2) in SO(2)(l) was studied by (77)Se NMR spectroscopy at -70 degrees C with both natural-abundance and enriched (77)Se-isotope samples (enrichment 92%). Both the natural-abundance and enriched NMR spectra showed the presence of previously known cations 1,4-Se(6)I(2)(2+), SeI(3)(+), 1,1,4,4-Se(4)I(4)(2+), Se(10)(2+), Se(8)(2+), and Se(4)(2+). The structure and bonding in 1,4-Se(6)I(2)(2+) and 1,1,4,4-Se(4)I(4)(2+) were explored using DFT calculations. It was shown that the observed Se-Se bond alternation and presence of thermodynamically stable 4ppi-4ppi Se-Se and 4ppi-5ppi Se-I bonds arise from positive charge delocalization from the formally positively charged tricoordinate Se(+). The (77)Se chemical shifts for cations were calculated using the relativistic zeroth-order regular approximation (ZORA). In addition, calculations adding a small number of explicit solvent molecules and an implicit conductor-like screening model were conducted to include the effect that solvent has on the chemical shifts. The calculations yielded reasonable agreement with experimental chemical shifts, and inclusion of solvent effects was shown to improve the agreement over vacuum values. The (77)Se NMR spectrum of the equilibrium solution showed 22 additional resonances. These were assigned on the basis of (77)Se-(77)Se correlation spectroscopy, selective irradiation experiments, and spectral simulation. By combining this information with the trends in the chemical shifts, with iodine, selenium, and charge balances, as well as with ZORA chemical shift predictions, these resonances were assigned to acyclic 1,1,2-Se(2)I(3)(+), 1,1,6,6-Se(6)I(4)(2+), and 1,1,6-Se(6)I(3)(+), as well as to cyclic Se(7)I(+) and (4-Se(7)I)(2)I(3+). A preliminary natural-abundance (77)Se NMR study of the soluble products of the reaction of (Se(4))[AsF(6)](2) and bromine in liquid SO(2) included resonances attributable to 1,1,4,4-Se(4)Br(4)(2+)(.) These assignments are supported by the agreement of the observed and calculated (77)Se chemical shifts. Resonances attributable to cyclic Se(7)Br(+) were also observed. The thermal stability of (Se(6)I(2))[AsF(6)](2).2SO(2)(s) was consistent with estimates of thermodynamic values obtained using volume-based thermodynamics (VBT) and the first application of the thermodynamic solvate difference rule for nonaqueous solvates. (Se(6)I(2))[AsF(6)](2).2SO(2)(s) is the first example of a SO(2) solvate for which the nonsolvated parent salt, (Se(6)I(2))[AsF(6)](2)(s), is not thermodynamically stable, disproportionating to Se(4)I(4)(AsF(6))(2)(s) and Se(8)(AsF(6))(2)(s) (DeltaG degrees for the disproportion reaction is estimated to be -17 +/- 15 kJ mol(-1) at 298 K from VBT theory).