Metformin along with chemotherapy/radiation improves outcomes in head and neck cancer patients

In continuation of my update on metformin

Researchers at the University of Cincinnati (UC) College of Medicine have found that adding increasing doses of an approved Type 2 diabetes drug, metformin, to a chemotherapy and radiation treatment regimen in head and neck cancer patients is not well tolerated if escalated too quickly, but allowing slower escalation could be beneficial.

These findings are being presented via poster June 4 at the 2016 American Society of Clinical Oncology (ASCO) Annual Meeting: Collective Wisdom, being held June 3-7 in Chicago.

Trisha Wise-Draper, MD, PhD, assistant professor in the Division of Hematology Oncology at the UC College of Medicine, a member of both the Cincinnati Cancer Center and UC Cancer Institute and principal investigator on this study, says retrospective studies have shown improved outcomes in tumors treated with chemotherapy and radiation if they were also on metformin for diabetes.

"In head and neck squamous cell carcinoma, which develops in the mucous membranes of the mouth, nose and throat, diabetic patients taking a medication called metformin had better overall survival compared to those not on metformin when also treated with chemotherapy and radiation," she says. "Additionally, pancreatic cancer patients treated with chemotherapy and metformin required higher doses of metformin--1,000 milligrams twice a day--to experience positive results.

"In basic science studies, metformin has been shown to stop mTOR, a molecular pathway present and active in this type of head and neck cancer, and pretreatment with metformin resulted in a decrease in the occurrence of oral cavity tumors in animal models. In this study, we wanted to see if the combination of escalating doses of metformin with the chemotherapy agent cisplatin and radiation for head and neck cancer tumors in non-diabetic patients would be effective."

Wise-Draper says that metformin, which is an approved Type 2 diabetes medication, was provided by their investigational pharmacy. Metformin was administered orally in escalating doses for 7 to 14 days prior to starting the cisplatin and radiation and continued throughout standard treatment. Blood samples were collected before and after metformin treatment as well as during chemotherapy. Flow cytometry, a technique used to count cells, was used to detect the percent of circulating immune activated cells, and clinical laboratory tests including glucose, B12 and C-peptide (an amino acid that is important for controlling insulin) were performed.

"This is part of an ongoing clinical trial," says Wise-Draper. "We found that eight patients with advanced head and neck cancer have been enrolled so far; we plan to have 30 total. Due to the relatively quick escalation of metformin, the patients' tolerance was poor with higher doses of metformin when initiated 7 days prior to their chemotherapy and radiation therapy regimen.
"Therefore, the protocol was modified to allow slower escalation over 14 days. The most common toxicities observed included nausea (71 percent of patients) and vomiting (43 percent of patients), increase in creatinine (57 percent of patients), decreased white blood cell count (43 percent of patients) and pain when swallowing (43 percent of patients) with only nausea being directly attributed to metformin and the rest attributed to cisplatin and radiation."

She adds that there wasn't a substantial change in T cell or glucose levels with administration of metformin in the small sample of patients but that there were increased C-peptide levels in response to metformin administration.

"These results show that the combination of metformin and cisplatin and radiation was poorly tolerated when metformin was escalated quickly. However, there has been no significant increase in side effects thus far with the addition of metformin," Wise-Draper says. "The trial is continuing with escalation of metformin over a longer period of time to provide more data; we will also try to increase our sample size."

FDA Expands Indication of Invokamet (canagliflozin/metformin HCl) to Include First-Line Treatment of Type 2 Diabetes

In continuation of my updates on INVOKANA® (canagliflozin) and metformin hydrochloride,

Janssen Pharmaceuticals, Inc. (Janssen), announced the U.S. Food and Drug Administration (FDA) has approved Invokamet, a fixed-dose combination therapy of INVOKANA® (canagliflozin) and metformin hydrochloride, for first-line treatment of adults with type 2 diabetes. With this new approval, Invokamet may now be prescribed in adults with type 2 diabetes who are not already being treated with canagliflozin or metformin and may benefit from dual therapy.

 metformin    canagliflozin

Invokamet, the first combination of a sodium glucose co–transporter 2 (SGLT2) inhibitor and metformin available in the United States, was previously approved by the FDA in August 2014 as an adjunct to diet and exercise to improve blood glucose control in adults with type 2 diabetes not adequately controlled by either canagliflozin or metformin, or who are already being treated with both medications separately.

“Physicians increasingly try to achieve greater initial blood sugar control by using dual therapy at the outset, versus single-agent therapy alone, especially for patients with higher A1C levels,” said John Anderson, M.D.*, Frist Clinic, Nashville, Tenn. “Invokamet combines two effective, complementary medicines—canagliflozin and metformin—into one convenient pill, to lower A1C significantly more than metformin alone.”

A1C is a measure of average blood glucose over the past two to three months; the American Diabetes Association recommends most adults with type 2 diabetes maintain A1C levels of 7 percent or less.[2]

The new Invokamet indication aligns with recent type 2 diabetes treatment guidelines, which recommend dual therapy for patients with higher A1C levels. Specifically, guidelines recommend dual therapy for patients who have an initial A1C level of 7.5 percent or higher;[3] and for those who have an initial level below 7.5 percent and do not achieve an A1C treatment goal after about three months on single therapy, often metformin.3,[4] In addition, dual or triple therapy is recommended as first-line therapy in asymptomatic patients with an initial A1C level above 9 percent.3

Studies have demonstrated that administration of Invokamet results in the same levels and effects of canagliflozin and metformin in the body as co-administration of corresponding doses of both drugs as individual tablets. Canagliflozin works with the kidneys to help adults with type 2 diabetes lose some sugar through the process of urination, and metformin decreases the production of glucose in the liver and improves the body's response to insulin. Invokamet should not be used in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis.1

Invokamet is available in four dose strengths, in tablets containing canagliflozin 50 milligrams (mg) or 150 mg, and metformin 500 mg or 1000 mg. The recommended dosing is twice daily. The prescribing information for Invokamet also contains a boxed warning for lactic acidosis, a rare, but serious complication that can occur due to metformin accumulation.1

“The available doses of Invokamet allow physicians to tailor therapy for individual patient needs and offer an alternative for people living with type 2 diabetes who may be able to reduce the number of pills they take each day,” said Paul Burton, M.D., Ph.D., Vice President, Medical Affairs, Janssen. “This expansion marks an important milestone as we continue to study Invokamet and INVOKANA®—the number-one prescribed SGLT2 inhibitor with more than 8 million prescriptions to date—for the treatment of type 2 diabetes.”

Phase 3 Study Supports Expanded Indication

The expanded indication for Invokamet was based largely on a 26-week, double-blind, active-controlled, multicenter Phase 3 study in 1,186 adults with type 2 diabetes inadequately controlled with diet and exercise, and who had not been treated previously with any glucose-lowering medications. The participants were assigned randomly to one of five treatment groups: metformin hydrochloride extended release (MET), canagliflozin 100 mg (CANA100), canagliflozin 300 mg (CANA300), canagliflozin 100 mg + MET (CANA100/MET), or canagliflozin 300 mg + MET (CANA300/MET). The mean baseline A1C across all groups was 8.8 percent. The primary endpoint was the change in A1C. A report on the study findings was published in Diabetes Care in March 2016.[5]

After 26 weeks, participants in the CANA100/MET and CANA300/MET groups had significantly greater decreases in A1C compared to those in the CANA100, CANA300 and MET groups: 1.77 percent and 1.78 percent vs. 1.37 percent, 1.42 percent and 1.3 percent, respectively (p-values for all differences between the combination therapies vs. individual therapies less than 0.001). Additionally, significantly more participants in the CANA100/MET and CANA300/MET groups compared to the MET group achieved the goal of reducing A1C to less than 7 percent: 47 percent and 51 percent vs. 38 percent, respectively (p less than 0.05 for both combination groups vs. MET).1

Other Phase 3 Studies of Canagliflozin-Metformin Therapy

The co-administration of canagliflozin—INVOKANA®—and metformin has been evaluated in six other Phase 3 clinical studies that enrolled 4,732 patients with type 2 diabetes and who were already taking glucose-lowering medications. The studies showed that the combination of INVOKANA® and metformin lowered blood sugar and, in pre-specified secondary endpoints, was associated with significant reductions in body weight and systolic blood pressure.

In two studies comparing INVOKANA® plus metformin to current standard treatments plus metformin—one studying sitagliptin and the other studying glimepiride—INVOKANA® dosed at 300 mg provided greater reductions in A1C levels and body weight than either comparator. The overall incidence of adverse events was similar with INVOKANA® and the comparators.

Results from the Phase 3 studies showed that INVOKANA® was generally well tolerated, and the most common adverse events include genital yeast infections, urinary tract infections, and changes in urination. The most common adverse reactions due to initiation of metformin, as noted in the prescribing information for that medication, are diarrhea, nausea, vomiting, flatulence, asthenia, indigestion, abdominal discomfort, and headache. Hypoglycemia does not occur in patients receiving metformin alone under usual circumstances of use. INVOKANA® can increase the risk of hypoglycemia when combined with insulin or a medication that increases insulin levels (e.g., a sulfonylurea). Therefore, a lower dose of insulin or insulin-raising medication may be required to minimize the risk of hypoglycemia when used in combination with Invokamet.

About Type 2 Diabetes

Of the approximately 29 million people who have diabetes in the United States, 90 to 95 percent of them have type 2 diabetes, which is chronic and affects the body's ability to metabolize sugar (glucose), and is characterized by the inability of pancreatic beta cell function to keep up with the body's demand for insulin

Could Diabetes Drug Metformin Help Keep People Slim?

New research suggests a first-line drug for treating type 2 diabetes   'metformin'  may help people with pre-diabetes maintain long-term weight loss.

People who lost weight while taking metformin maintained a loss of about 6% of their body weight for six to 15 years. People who lost weight through lifestyle changes -- eating healthily and exercising regularly -- managed to keep off just under 4% of their initial body weight for the same period, the study found.

Metformin doesn't seem to be particularly helpful for shedding pounds in the first place, though. In fact, an earlier phase of the study found that people were much more likely to lose 5% or more of their body weight through lifestyle changes -- healthy eating and exercising -- than by using metformin.

"Although lifestyle changes were superior for inducing weight loss early on, metformin was better for long-term weight maintenance," said senior study author Dr. Kishore Gadde. He's a professor in heart disease prevention at the Pennington Biomedical Research Center in Baton Rouge, La.

Not everyone is convinced that metformin can keep you slim, however. After reviewing the findings, Dr. Joel Zonszein, director of the Clinical Diabetes Center at Montefiore Medical Center in New York City, said, "This study was very well done, but it doesn't show metformin is effective for everyone. The ones on metformin who did lose weight only regained a little less weight."

He added that metformin isn't well-tolerated by a lot of people. It can cause digestive problems, such as nausea and diarrhoea.

An  effective intervention for losing weight and maintaining that loss is clearly needed. Nearly three-quarters of the American population is overweight or obese -- a major risk factor for type 2 diabetes, according to the U.S. Centers for Disease Control and Prevention.

Losing a significant amount of weight more than 5% of your body weight  seems to help prevent pre-diabetes from turning into type 2 diabetes, and can help delay the progression of type 2 diabetes.

The latest study was a continuation of the three-year diabetes prevention clinical trial that compared three different groups of people with pre-diabetes to see what type of intervention would help prevent type 2 diabetes from developing. One group was given metformin, another was coached on intensive lifestyle changes, and the third group was given a placebo.

This study found that lifestyle changes led to the greatest initial weight loss, followed by the metformin group, according to Gadde.

From the original study group -- more than 3,000 people -- just over 1,000 lost more than 5% of their body weight.

The researchers followed this group for as long as 15 years to see who maintained their weight loss.

People taking metformin had the greatest weight loss from years six to 15, according to the study. The study also found that being older and losing a greater amount of weight in the first year were consistent predictors of lasting weight loss, the study authors said.

Gadde said it's not exactly clear why the metformin group was better at maintaining weight loss. "Metformin does reduce food intake a little bit, but it's not a dramatic effect. And, from what we know, it doesn't significantly alter energy expenditure."

He said other recent research suggests that metformin may alter the body's microbiome (the healthy bacteria in your gut). It also seems that metformin may have some effects on muscle function. But Gadde said, more research is necessary to know for sure.

Could Diabetes Drug Metformin Help Keep People Slim?

Oral antidiabetic drug modulates the body's nitrogen and urea metabolism

In continuation of my updates on metformin

The most frequently prescribed oral antidiabetic drug metformin significantly affects metabolic pathways. This was reported by scientists from the Helmholtz Zentrum München together with colleagues from the German Diabetes Center (DDZ) in Düsseldorf. The underlying study was conducted with further scientists of the German Center for Diabetes Research (DZD). These results have now been published in the journal 'Diabetes'.

Metformin is a widespread oral medication to increase insulin sensitivity in patients with type 2 diabetes (T2D). According to a number of studies, it additionally reduces the risk of cardiovascular complications. Last year, a team led by Dr. Rui Wang-Sattler discovered that metformin intake lowers the levels of the harmful LDL cholesterol by activating the AMPK protein complex. Dr. Wang-Sattler is head of the "Metabolism" research group in the Research Unit of Molecular Epidemiology at the Institute of Epidemiology II at the Helmholtz Zentrum München. Her group aims to understand the molecular mechanisms that underlie the activity of metformin.

Metformin intake changes metabolite profiles in population-based KORA study

In the present work, the interdisciplinary team of scientists was able to explain a further feature of the drug: "Our results show that metformin also modulates the body's nitrogen and urea metabolism," first author Jonathan Adam summarizes.

In close collaboration with Dr. Stefan Brandmaier and other colleagues, he examined the metabolite profiles (353 small molecules) of KORA participants. The researchers compared T2D patients treated with metformin (a total of 74) with those not being treated with metformin (115) and looked for differences in the distribution of metabolites in the blood. They subsequently confirmed the findings in samples of more than 1500 participants.

Amino acid levels provide a crucial hint

Changes in the amino acid citrulline concentration caused by metformin intake were particularly significant. The amino acid citrulline (named after Citrullus vulgaris, the watermelon, where it is found in large quantities) showed significantly lower levels in samples of T2D patients treated with metformin than in untreated ones. The researchers propose that this is a further consequence of metformin's AMPK activation. "Our analysis indicates that the activation of the AMPK pathway by metformin affects nitrogen and urea metabolism through a further enzyme, which thus lowers the citrulline levels", reports Rui Wang-Sattler.

Accordingly, the scientists suspect that the additional intake of citrulline could have a positive effect on the cardiovascular system in patients being treated with metformin. As a follow-up study, the team plans to analyze the metformin-associated effects on other central metabolic pathways, such as the citric acid cycle.

Metformin helps dieting teens to lose weight....

We know that Metformin  (see structure), is a  biguanide hypoglycemic  agent used in the treatment of non-insulin-dependent diabetes mellitus not responding to dietary modification. Metformin improves glycemic control by improving insulin sensitivity and decreasing intestinal absorption of glucose. Metformin's pharmacologic mechanisms of action are different from other classes of oral antihyperglycemic agents. Metformin decreases hepatic glucose production, decreases intestinal absorption of glucose and improves insulin sensitivity by increasing peripheral glucose uptake and utilization. In my earlier blogs, I have covered the recent (findings)  updates on metformin.

Now researchers  lead by Dr. Darrell Wilson (from Division of Pediatric Endocrinology and Diabetes, Stanford University)  have found that metformin appears to help overweight teenagers lose weight when combined with a program designed to help them change their lifestyle habits.

As per the claim by the authors though metformin hydrochloride is  used as a primary or adjunctive treatment in obese  nondiabetic adolescents there are limited short-term data to support this therapy  and also it is unclear whether any observed effects of metformin on body mass index. Therefore  the researchers conducted a 48-week randomized, double-blind, placebo-controlled trial of extended-release (XR) metformin therapy in nondiabetic obese adolescents  followed by a 48-week monitoring period after completion of treatment.

Researchers found that the addition of metformin to a lifestyle change intervention for a period of 12 months resulted in a significant improvement of BMI regardless of baseline fasting insulin levels, that persisted for 12 to 24 weeks after cessation of drug treatment. The mean (SE) reduction in BMI of –1.1 (0.5) at 1 year was comparable with that observed in other randomized controlled trials of metformin treatment in obese adolescents, although these randomized controlled trials involved shorter treatment duration (about 6 months), targeted obese children with additional diabetes risks, and had smaller sample sizes.

The mechanisms of action for these effects have not fully been elucidated but may involve beneficial effects on carbohydrate and lipid metabolism, mediated through adenosine monophosphate kinase.

Researchers conclude that  "metformin  in combination with lifestyle modification, had a small but statistically significant effect to reduce BMI in obese adolescents; this effect waned within 12 to 24 weeks of discontinuing metformin treatment". These results indicate that metformin may have an important role in the treatment of adolescent obesity. Longer-term studies will be needed to define the effects of metformin treatment on obesity-related disease risk in this population....

Ref : http://archpedi.ama-assn.org/cgi/content/full/164/2/116?home

Cardioprotective effect proposed for metformin

In continuation of my update on metformin

 

A large retrospective analysis suggests that metformin could be cardioprotective in insulin-dependent patients with Type 2 diabetes.

The findings, based on data from the UK Clinical Practice Research Datalink, found a reduced risk of major adverse cardiac events (MACE) and all-cause mortality among patients taking the drug.

To minimise the effects of confounding by indication, Craig Currie (Cardiff University, UK) and co-workers analysed only patients who had been started on insulin, with metformin started simultaneously or added later.

None of the 12,020 patients analysed had prior MACE or cancer at baseline. During an average 3.5 years of follow-up, the MACE rate among the 5536 patients taking insulin plus metformin was 15.9 per 1000 person-years, compared 26.3 with per 1000 person-years among the 6484 patients taking insulin monotherapy. The all-cause mortality rate was also lower, at 21.2 versus 61.3 deaths per 1000 person-years.

After accounting for multiple confounders, including cumulative insulin exposure, patients given metformin had a significant 25% reduced risk of MACE and a 40% reduced risk of mortality, the team reports in  PLoS ONE

Among patients matched for the propensity to be prescribed metformin, outcome rates were 14.9 versus 22.2 per 1000 person-years for MACE and 23.1 versus 44.4 per 1000 person-years for mortality. The mortality difference persisted after accounting for confounders, at a 30% reduction, although the difference in MACE became nonsignificant.

The team found no association between cancer risk and metformin treatment, despite previous suggestions that it may have a protective effect.

Currie et al note that the various contraindications and cautions for metformin treatment, such as tissue hypoxia and renal impairment, mean that "the population of people receiving insulin in combination with metformin may be healthier than the monotherapy group."

Given this, and other drawbacks of a retrospective study, they conclude that more research is needed "to determine the risks and benefits of insulin in type 2 diabetes and the possible benefits associated with the administration of concomitant metformin."

 Ref : http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0153594

Statin use alone or with metformin may increase survival in high-risk prostate cancer patients

In continuation of my update on metformin

Among high-risk prostate cancer patients - those with high PSA and Gleason scores of 8 or more - many will develop a difficult-to-treat disease. Preliminary research suggests that two commonly prescribed medications, cholesterol-lowering statins and the diabetes therapy metformin may have anticancer effects. However, it is unclear which of these two medications - commonly prescribed together -- contributes the most and whether they can impact high-risk prostate cancer. New research shows that statins, alone or with metformin, increase survival in men with high-risk prostate cancer.

"Both metformin and statins have been associated with longer life in prostate cancer patients, yet because they are commonly prescribed together, no study we know of has looked at these two medications separately," says senior author Grace Lu-Yao, PhD, associate director of Population Science at the Sidney Kimmel Cancer Center--Jefferson Health, one of only eight NCI-designated cancer centers nationwide with a prostate cancer program of excellence.

The study, published in Cancer Medicine on Feb 8th, looked at a number of statin therapies, and metformin, an anti-diabetic medication, in high-risk prostate cancer populations.

Using data from the Surveillance, Epidemiology and End Results (SEER-18) database linked with Medicare files, Dr. Lu-Yao and colleagues looked at patients diagnosed with cancer from 2007 through to 2011. Based on 12,700 patients, the researchers observed that statins alone or in combination with metformin was significantly associated with reduced mortality from all causes.

Dr. Lu-Yao and colleagues saw the highest median survival of 3.9 months in men who took both metformin and statins, 3.6 with statins alone and 3.1 years with metformin alone. The median survival for those who did not use either drug was also 3.1 years.

With respect to prostate mortality, metformin plus statin was associated with a 36% reduction in risk of death followed by statins alone. Those taking metformin alone were relatively rare, and there was no significant association with all-cause mortality."

Interestingly, the study revealed that men who took atorvastatin, pravastatin, or rosuvastatin - but not lovastatin - demonstrated a reduction in mortality compared with non-users, which is consistent with the findings from a recent population-based cohort study using Taiwan National Health Insurance Research Data. The Taiwanese research showed that these three statins are more effective at lowering triglycerides and low-density lipoprotein cholesterol and raising high-density lipoprotein cholesterol than other statins in patients with hypercholesterolemia.

Of the three statins studied, men on atorvastatin did have a longer median time to progression on androgen deprivation therapy compared to those who weren't treated with statins. "Although the exact mechanisms remain unknown, it is worth noting that atorvastatin exhibits a potent lipid-lowering effect per dose of any statin, and has the greatest bioavailability and one of the longest half-lives," says to Dr. Lu-Yao.

The data presented in the current study provide crucial insight for the design of future randomized clinical trials of statin for high-risk patients with prostate cancer. Based on the existing evidence, a well-designed clinical trial is warranted to investigate the roles of statins and combination statins/metformin to reduce the mortality cancer of the prostate.

"Our study showed that the effects were more pronounced in patients taking statins after the diagnosis of prostate cancer, 54% reduction in PCA mortality among patients with high-risk prostate cancer," says Lu-Yao. "This magnitude of reduction is comparable to the results of men treated with androgen signaling inhibitors." Statins are relatively inexpensive with good safety records. Further studies to understand the mechanisms of the observed association and its potential clinical utility are warranted.

https://onlinelibrary.wiley.com/doi/full/10.1002/cam4.2862

FDA Approves Trijardy XR (empagliflozin/linagliptin/metformin) for Type 2 Diabetes in Adults

In continuation of my update on empagliflozin/linagliptin/metformin 

    

The U.S. Food and Drug Administration (FDA) has approved Trijardy XR (empagliflozin/linagliptin/metformin hydrochloride extended release tablets) to lower blood sugar in adults with type 2 diabetes, along with diet and exercise. Trijardy XR provides three type 2 diabetes medicines in one pill, including Jardiance® (empagliflozin), Tradjenta® (linagliptin) and metformin hydrochloride extended release. Trijardy XR is marketed by Boehringer Ingelheim Pharmaceuticals, Inc. and Eli Lilly and Company (NYSE: LLY).

"Many adults living with type 2 diabetes who are already on a treatment plan including multiple medications still struggle to keep their blood sugar under control, and may require additional agents to reach their A1C targets," said Ralph DeFronzo, M.D., professor and diabetes division chief, UT Health San Antonio. "Adding new medicines to an individual's plan can be challenging for some, which is why new treatment options that can help improve blood sugar without the burden of an increased pill count are important. In addition, type 2 diabetes is a complex disease that often requires the use of multiple antidiabetic medications to improve glycemic control. Having three different diabetes medications in a single tablet is an important advance in diabetes treatment."

In the U.S., both Jardiance and Tradjenta are once-daily tablets used along with diet and exercise to lower blood sugar in adults with type 2 diabetes. Jardiance is also approved to reduce the risk of cardiovascular death in adults with type 2 diabetes who have known cardiovascular disease. Jardiance is not for people with type 1 diabetes or for people with diabetic ketoacidosis (increased ketones in the blood or urine). Tradjenta is not for people with type 1 diabetes or for the treatment of diabetic ketoacidosis. Tradjenta has not been studied in people with a history of pancreatitis and it is unknown if using Tradjenta increases the risk of developing pancreatitis in these people. 

"We are proud to offer Trijardy XR as a new once-daily option combining three well-established medicines, including an extended-release version of metformin, the most commonly prescribed initial treatment for type 2 diabetes, Jardiance, the most prescribed SGLT2 inhibitor, and Tradjenta, the only single-dose DPP-4 inhibitor," said Mohamed Eid, M.D., M.P.H., M.H.A., vice president, Clinical Development & Medical Affairs, Cardio-Metabolism & Respiratory Medicine, Boehringer Ingelheim Pharmaceuticals, Inc. "We believe Trijardy XR has the potential to help adults with type 2 diabetes conveniently manage their treatment, especially those who are taking other medications and working on the necessary lifestyle changes."

Trijardy XR is not recommended for people with type 1 diabetes or diabetic ketoacidosis (increased ketones in the blood or urine). Trijardy XR has not been studied in patients with a history of pancreatitis. It is unknown whether patients with a history of pancreatitis are at an increased risk for the development of pancreatitis while using Trijardy XR. The labeling for Trijardy XR contains a warning for lactic acidosis, a rare but serious complication that can occur due to metformin accumulation, and is common to all products containing metformin.

The FDA approval of Trijardy XR is based on two randomized open-label trials that assessed the bioequivalence of empagliflozin, linagliptin and metformin hydrochloride extended release fixed-dose combination tablets and their individual components in healthy adults. The safety profile of Trijardy XR was found to be consistent with its individual components.

"The approval of Trijardy XR reflects our commitment to the diabetes community and to innovation that addresses evolving needs," said Jeff Emmick, M.D. Ph.D., vice president, Product Development, Lilly. "We developed Trijardy XR because many people with type 2 diabetes need help managing this complex condition without adding more pills to their treatment plan. We look forward to making this new option available soon."

Trijardy XR is not for people who have severe kidney problems, end stage renal disease, or are on dialysis, have a serious condition called metabolic acidosis or diabetic ketoacidosis (increased ketones in the blood or urine), or are allergic to Jardiance, Tradjenta, metformin, or any of the ingredients in Trijardy XR. There have been postmarketing reports of acute pancreatitis, including fatal pancreatitis, in patients taking linagliptin, a component of Trijardy XR. Take careful notice of potential signs and symptoms of pancreatitis. If pancreatitis is suspected, promptly discontinue Trijardy XR and initiate appropriate management. It is unknown whether patients with a history of pancreatitis are at increased risk for the development of pancreatitis while using Trijardy XR.

Trijardy XR will be available in four different dosages, including: 5 mg empagliflozin/2.5 mg linagliptin/1000 mg metformin HCl extended-release; 10 mg empagliflozin/5 mg linagliptin/1000 mg metformin HCl extended-release; 12.5 mg empagliflozin/2.5 mg linagliptin/1000 mg metformin HCl extended-release; and 25 mg empagliflozin/5 mg linagliptin/1000 mg metformin HCl extended-release.

What is Trijardy XR?

Trijardy XR is a prescription medicine that contains 3 diabetes medicines, empagliflozin (JARDIANCE), linagliptin (TRADJENTA), and metformin hydrochloride. Trijardy XR can be used along with diet and exercise to lower blood sugar in adults with type 2 diabetes, and in adults with type 2 diabetes who have known cardiovascular disease when empagliflozin (JARDIANCE), one of the medicines in Trijardy XR, is needed to reduce the risk of cardiovascular death.

Trijardy XR is not for people with type 1 diabetes, or for people with diabetic ketoacidosis (increased ketones in the blood or urine).

If you have had pancreatitis (inflammation of the pancreas) in the past, it is not known if you have a higher chance of getting pancreatitis while you take Trijardy XR.

https://www.drugs.com/history/trijardy-xr.html

FDA Expands Indication For Type 2 Diabetes Treatment Synjardy (Empagliflozin/Metformin Hydrochloride) To Include Treatment-Naïve Adults

In continuation of my update on empagliflozin and metformin

The U.S. Food and Drug Administration has approved an expanded indication for Synjardy (empagliflozin and metformin hydrochloride) tablets to include treatment-naïve adults with type 2 diabetes (T2D). Synjardy, from Boehringer Ingelheim and Eli Lilly and Company (NYSE: LLY), is indicated as an adjunct to diet and exercise to improve glycemic control in adults with T2D when treatment with both empagliflozin and metformin is appropriate.

empagliflozin Metformin

Synjardy is a combination of empagliflozin (Jardiance) and metformin — two medicines with complementary mechanisms of action — to help control blood glucose in adults with T2D. Empagliflozin, a sodium glucose co-transporter-2 inhibitor, removes excess glucose through the urine by blocking glucose re-absorption in the kidney. Metformin, a commonly prescribed initial treatment for T2D, lowers glucose production by the liver and its absorption in the intestine.

"Type 2 diabetes is a complex condition, which often requires that people take more than one treatment to manage their blood sugar," said Paul Fonteyne, president and CEO, Boehringer Ingelheim Pharmaceuticals, Inc. "The expanded indication for Synjardy further validates the potential of this combination therapy to help adults with type 2 diabetes who are not at goal, including those already being treated and, now, those at the beginning of their treatment journey."

The Synjardy label was updated to include results from a phase III, double-blind, randomized, active-controlled study that evaluated the efficacy and safety of empagliflozin in combination with metformin as initial therapy compared with the individual components. In the study, at 24 weeks, the combination of empagliflozin 10 mg or 25 mg with metformin 1000 mg or 2000 mg resulted in significant reductions in A1C (a measure of average blood glucose over the past two to three months) compared with the corresponding dose of either component alone.

Synjardy can cause serious side effects, including Lactic Acidosis (a buildup of lactic acid in the blood). Metformin, one of the medicines in Synjardy, can cause lactic acidosis, a rare, but serious condition that can cause death. Lactic acidosis is a medical emergency and must be treated in a hospital. Synjardy is not for the treatment of type 1 diabetes or diabetic ketoacidosis.

Drug combination could help reduce risk of death in type 2 diabetes

In continuation of my update on metformin

People with type 2 diabetes treated with insulin plus metformin had a reduced risk of death and major cardiac events compared with people treated with insulin alone, a new study by Cardiff University shows.

Led by Professor Craig Currie of the University's School of Medicine, the retrospective research looked at people with type 2 diabetes who were treated with insulin with or without metformin from the year 2000 onwards.

12,020 people were identified from a general practice data source, and the research team tracked them for three and a half years on average, from the time they were first prescribed insulin.

The researchers found than when used in conjunction with insulin, metformin had the potential to reduce mortality and heart attacks. They also found that there was no difference in the risk of cancer between people treated with insulin as a single therapy or in combination with metformin.

Professor Currie said: "Since 1991, the rate of insulin use in type 2 diabetes increased more than six-fold in the UK. In more recent years, metformin has also been used alongside insulin as a treatment.

"Previously, our work showed that increased insulin dose is linked with mortality, cancer and heart attacks. Existing studies have also shown that metformin can attenuate the risks associated with insulin.

"In this research we examined insulin dose along with the impact of combining insulin with metformin. We found that there was a considerable reduction in deaths and heart problems when this cheap and common drug was used in conjunction with insulin.

Around 3.9m people live with diabetes in the UK, with more than 90% of those affected having type 2 diabetes.

"While this research indicates the potential of using these treatments together, further studies are needed to determine the risks and benefits of insulin in type 2 diabetes and the possible benefits associated with the administration of metformin alongside insulin," added Professor Currie.

Diabetes drug use during pregnancy may increase risk of obesity or overweight in children

In continuation of my update on metformin

When women take the common diabetes medication metformin during pregnancy, it may put their children at increased risk of having obesity or overweight.

A growing number of pregnant women are taking metformin to treat gestational diabetes or a condition called polycystic ovary syndrome (PCOS). PCOS is a common cause of infertility and can put women at risk of developing diabetes and other metabolic health problems. PCOS affects an estimated 7 percent to 10 percent of women of childbearing age, according to the Hormone Health Network.

When pregnant women with PCOS or gestational diabetes take metformin, the medication crosses the placenta and is passed to the fetus.

"Our findings indicate the offspring of women who took metformin for PCOS during pregnancy are more likely to meet the criteria for obesity or overweight than children whose mothers were given a placebo during pregnancy," said the study's first author, Liv Guro Engen Hanem, M.D., of the Norwegian University of Science and Technology in Trondheim, Norway. "The results were surprising, since limited past research in this area had suggested metformin would have a protective effect on the children's metabolic health."

The researchers invited parents of 292 children who participated in two previous randomized clinical trials to be part of this study. In the previous trials, pregnant women with PCOS were assigned to take either metformin or a placebo during pregnancy. The researchers wound up reviewing body mass index (BMI) and other measurements for 161 children born following the two earlier studies.

At four years of age, the children whose mothers were randomized to metformin during pregnancy tended to weigh more than the children whose mothers took the placebo. Although metformin did not appear to affect birth weight, the trend became apparent when children reached six months of age. At the age of four years, the children in the metformin group had higher BMI scores and were more likely to meet the criteria for obesity or overweight than children in the placebo group.

"Few studies have examined the long-term health of children born to women with PCOS who took metformin," Hanem said. "Our findings indicate more research is needed to determine its effects on children who were exposed in the womb."

Ref : https://www.endocrine.org/news-room/2018/diabetes-drug-use-during-pregnancy-linked-to-childs-weight

Diabetes drug use during pregnancy may increase risk of obesity or overweight in children

2 Drugs Better Than 1 to Treat Youth With Type 2 Diabetes

2 Drugs Better Than 1 to Treat Youth With Type 2 Diabetes: A combination of two diabetes drugs, metformin and rosiglitazone, was more effective in treating youth with recent-onset type 2 diabetes than metformin alone, a study funded by the National Institutes of Health (NIH) has found. Adding an intensive lifestyle intervention to metformin provided no more benefit than metformin therapy alone.

The study also found that metformin therapy alone was not an effective treatment for many of these youth. In fact, metformin had a much higher failure rate in study participants than has been reported in studies of adults treated with metformin alone.

The study found that treatment with metformin alone was inadequate for maintaining acceptable, long-term, blood glucose control in 51.7 percent of youth over an average follow-up of 46 months. The failure rate was 38.6 percent in the metformin and rosiglitazone group, a 25.3 percent reduction from metformin alone. In the metformin plus lifestyle group the failure rate was 46.6 percent.

FDA Approves Qternmet XR (dapagliflozin, saxagliptin and metformin hydrochloride) for Type 2 Diabetes

In continuation of my update on dapagliflozin, and metformin hydrochloride

 

Dapagliflozin            Saxagliptin                                   and  (Metformin)

The US Food and Drug Administration (FDA) has approved Qternmet XR(dapagliflozin, saxagliptin and metformin hydrochloride) extended release tablets as an oral adjunct treatment to diet and exercise to improve glycaemic control in adults with type-2 diabetes (T2D).

The approval is based on two Phase III trials, which evaluated combinations of dapagliflozin and saxagliptin on a background of metformin over 24 weeks, in patients with inadequately-controlled T2D.

In one trial, treatment with 5mg dapagliflozin/5mg saxagliptin in addition to metformin demonstrated statistically-significant decreases in HbA1c (average blood glucose levels), and an increase in the number of patients achieving the recommended HbA1c treatment goal of <7%. In the second trial, treatment with 10mg dapagliflozin/5mg saxagliptin in addition to metformin extended release demonstrated statistically-significant decreases in HbA1c, and an increase in the number of patients achieving an HbA1c <7%.

The safety results of the individual medicines in these trials were consistent with their known profile.

About Qternmet XR

Qternmet XR is a once-daily, oral medicine compromised of the selective sodium‑glucose cotransporter-2 (SGLT-2) inhibitor dapagliflozin, the dipeptidyl peptidase‑4 (DPP‑4) inhibitor saxagliptin and metformin hydrochloride extended release. Qternmet XR is approved in the US as an adjunct to diet and exercise to improve glycaemic control in adults with type-2 diabetes.

https://en.wikipedia.org/wiki/Dapagliflozin

https://en.wikipedia.org/wiki/Saxagliptin

https://www.drugbank.ca/drugs/DB06335

https://www.drugbank.ca/drugs/DB00331

https://en.wikipedia.org/wiki/Metformin

FDA Approves Qternmet XR (dapagliflozin, saxagliptin and metformin hydrochloride) for Type 2 Diabetes

Metformin - safe for patients with advanced heart failure and diabetes mellitus

In continuation of my update on Metformin,   I am sharing herewith  something interesting info,  about the same drug. Now researchers from David Geffen School of Medicine at UCLA,  have found that metformin, a drug often used in the treatment of diabetes mellitus, is safe for use in treating patients who have both diabetes and advanced heart failure. 

Diabetes increases not only the risk of developing heart failure, but also the risk of death among heart failure patients. This is due in large part to the fact that diabetes, because it increases the amounts of sugar and fat circulating in the bloodstream, accelerates the onset of coronary atherosclerosis. This hardening and thickening of blood vessels is the hallmark of atherosclerotic heart disease, the most common cause of death. The optimal treatment for high glucose and fat blood levels among heart failure patients has not been demonstrated.

The new study involved 401 patients of an average age of 56, with type II diabetes and advanced systolic heart failure. This patient cohort was followed for 14 years in a comprehensive heart failure management program.

The study results suggest that, in patients with both advanced heart failure and diabetes, use of metformin is safe, and may be associated with better heart failure survival.

Interestingly, the diabetes drug metformin previously carried a "black box warning" from the FDA against its use in treating diabetes in heart failure patients and that is why most many physicians have been reluctant to use metformin and other similar medications to treat this patient group. However, analysis by the researchars, shows that using metformin to treat diabetes in patients with advanced, systolic heart failure is not only safe, but may also play a role in improving outcomes compared to conventional diabetes care. As per the claim by Dr Gregg Fonarow, coresearcher,  metformin improves myocardial function via activation of a signaling mechanism (AMP-activated protein kinase) independent of antihyperglycemic effects. Together, these studies suggest that metformin may be cardioprotective by augmenting heart function at the molecular level, and should be further investigated as a treatment for heart failure, irrespective of diabetes....

Ref : http://www.newsroom.ucla.edu/portal/ucla/ucla-study-demonstrates-that-metformin-150497.aspx

Metformin can reduce risk of open-angle glaucoma in people with diabetes

In continuation of my update on metformin

Taking the medication metformin hydrochloride was associated with reduced risk of developing the sight-threatening disease open-angle glaucoma in people with diabetes, according to a study published online by JAMA Ophthalmology.

Medications that mimic caloric restriction such as metformin can reduce the risk of some late age-onset disease. It is unknown whether these caloric mimetic drugs affect the risk of age-associated eye diseases such as macular degeneration, diabetic retinopathy, cataract or glaucoma.

Researcher Julia E. Richards, Ph.D., of the University of Michigan, Ann Arbor, and co-authors examined metformin use and the risk of open-angle glaucoma (OAG) using data from a large U.S. managed care network from 2001 through 2010.

Of 150,016 patients with diabetes, 5,893 (3.9 percent) developed OAG. Throughout the study period, 60,214 patients (40.1 percent) filled at least one metformin prescription; 46,505 (31 percent) filled at least one sulfonylurea prescription; 35,707 (23.8 percent) filled at least one thiazolidinedione prescription; 3,663 (2.4 percent) filled at least one meglitinide prescription; and 33,948 (22.6 percent) filled at least one insulin prescription. Some patients filled prescriptions for multiple medications.

Metformin can reduce risk of open-angle glaucoma in people with diabetes

Diabetes drug metformin could help reduce toxic acid levels linked to MSUD

In continuation of my update on metformin 

Maple Syrup Urine Disease (MSUD) is a rare inherited metabolic disorder involving the dysfunction of an enzyme which breaks down three essential amino acids: leucine, isoleucine and valine. Left untreated, infants die from a toxic buildup of resulting keto-acids within weeks of birth. Those who are diagnosed early can live a normal life, but are forced to eat a very controlled, formula-based diet. The only proven treatment for the disease, which is characterized by sweet-smelling urine, is a liver transplant. Publishing in Scientific Reports, researchers at the Buck Institute show that the widely-used diabetes drug metformin reduces the toxic acid levels associated with MSUD in both skin cells derived from MSUD patients and in mice. The discovery offers the possibility of a new treatment for a disorder identified 1 in 180,000 births.

Senior author and Buck faculty Arvind Ramanathan, PhD, says metformin reduced the levels of toxic ketoisocaproic acid (KIC) in patient-derived fibroblasts by 20 to 50 percent and significantly reduced KIC levels in the skeletal muscle of mice bred to have the disease by 69 percent. "We think there is a clear path to a clinical trial and we are hoping that physicians who treat MSUD patients will start pushing in that direction," he said. "There is a definite need for novel interventions."

Ramanathan, who specializes in metabolomics, came to the MUSD discovery as he was studying various compounds and the enzymes they impact in the context of aging. The work could provide a mechanistic explanation for metformin's success in controlling diabetes and possibly extending healthspan in both animals and humans. The research also highlights similarities between a rare pediatric disease and normal aging - and shows how studying one can inform the other.

Researchers studied the enzyme BCKDH, which is defective in MSUD and also decreases in activity with normal aging. Ramanathan says decreased BCKDH is implicated in obesity and diabetes; he believes it may be involved in a number of other age-related conditions as well. Ramanathan also studied an enzyme upstream of BCKDH - called BCAT. He says in MSUD, BCAT converts leucine, isoleucine and valine to toxic ketones in the mitochondria of skeletal muscle -resulting in the muscle weakness and atrophy associated with MUSD. "We think the same process may be afoot with age-related sarcopenia and frailty," he said. "Interestingly, metformin interacts with BCAT and in our MSUD mice treatment with metformin significantly reduced toxic acid buildup in the skeletal muscle."

"This is a prime example how aging research can have a significant impact on people at any age and the work also highlights the value of studying drugs already approved by the FDA," said Brian Kennedy, PhD, senior co-author and Buck Institute CEO. "In this case, we hope our discovery will help those living with MUSD. We plan on building on these insights to further our research aimed at extending the healthy years of life for all of us."