Saturday, July 12, 2025

Hope & Weekly Pill: Trelagliptin in Focus

Hope in a Weekly Pill: A Doctor’s Reflection

The life of a doctor on a 24‑hour shift is like being caught in a storm. My duty starts at 9 a.m. and ends at 9 a.m. the next day. There’s barely a quiet moment. It’s a continuous loop of emergencies, decisions, and caring for people on the edge. By 5:30 p.m., even though the night lies ahead, the tiredness sinks deep into the bones. There’s no real break — not even for 30 minutes. This life, though meaningful, slowly chips away at health, sleep, and sometimes, the spirit.

In the emergency room, we often see patients with longstanding diabetes. Many have struggled for more than a decade. They are tired. Tired of taking pills — morning, noon, and night. They say it out loud: “Pills, pills, and more pills!” This fatigue leads to missed doses, rising sugar levels, and eventual organ damage—a painful cycle we see too often.

But even in this chaos, there's a quiet thread among us—shared knowledge. It’s not formal. It’s just someone sending a message, a link, a photo on WhatsApp, hoping to keep colleagues informed.

Yesterday, in a rare moment of pause, I checked my phone. A senior had sent a picture of a new medicine — Trelaglip. The words jumped out: “Once Weekly Oral DPP‑4i.” My heart skipped a beat. Could this be real?

I read the message: “Same day, every week. Trelaglip tablets.” That was it. A once-weekly oral medicine for type 2 diabetes. No more three-times-a-day routine. One tablet a week. Like Vitamin D. Simple. Manageable. Revolutionary.

If it works as promised, it could change everything. Patients might finally stick to treatment. That means better sugar control, fewer complications, and possibly, a better life. We’ve had weekly injections before. But a pill? That’s far more acceptable.

Of course, cost remains a question. But if the drug is effective, prices may fall. It could reach many, not just a few. For public health, it could be a game‑changer in our fight against diabetes.

It’s strange—how during a hectic shift, a colleague’s simple message can feel like a small light in the dark. These moments remind me why we keep going, even when exhausted. We’re all striving to improve patient lives.

Sometimes, hope arrives not in big discoveries, but in a small tablet taken once a week — and in a brief moment of shared belief.


Once‑Weekly Oral Antidiabetic Therapy: A Public Health Perspective for India

Introduction

The rise of once‑weekly oral antidiabetic agents, such as Trelagliptin (a DPP‑4 inhibitor), could represent a breakthrough in managing type 2 diabetes mellitus (T2DM). In India, where diabetes prevalence is escalating, this innovation may reduce long‑term complications and improve adherence.

The Public Health Burden

Diabetes is a chronic disease with serious complications affecting both individuals and health systems:

  • Microvascular: Retinopathy, nephropathy, neuropathy.
  • Macrovascular: Heart attack, stroke, peripheral artery disease.
  • Infections: Increased susceptibility due to reduced immunity.
  • Quality of Life: Chronic disability and loss of productivity.

These complications heavily burden India’s healthcare resources and economy due to loss of productive life‑years.

The Role of Once‑Weekly Therapy

1. Medication Adherence

  • Pill Fatigue: Reducing dose frequency simplifies treatment.
  • Compliance: Less frequent dosing supports more consistent use and delayed progression.

2. Complication Reduction

  • Microvascular: Better control reduces risks of blindness, dialysis, amputations.
  • Cardiovascular: Stable glucose lowers heart attack and stroke incidence.
  • Healthcare Demand: Fewer complications reduce hospital and specialist burden.

3. Quality of Life

  • Self‑Confidence: Simpler regimens boost patient empowerment.
  • Mental Health: Reducing daily reminders of illness eases stress.
  • Productivity: Healthier patients support economic activity and relieve caregiver strain.

Challenges for Integration

  • Cost‑effectiveness: Sustainable pricing and generics/essential medicine inclusion are needed.
  • Rural Accessibility: It must reach primary health centers and NCD programs.
  • Provider Training: Community doctors and health workers need education and support.

Trelagliptin: Pharmacology and Clinical Profile

Introduction

Trelagliptin is a once‑weekly oral DPP‑4 inhibitor approved in Japan (March 2015) and India (December 2024) for T2DM management. It enhances incretin activity to improve glycemia with low hypoglycemia risk.

Mechanism of Action

  • Inhibits DPP‑4, preserving GLP‑1 and GIP to enhance glucose‑dependent insulin and suppress glucagon.
  • Slows gastric emptying; may support β‑cell health.
  • High specificity (IC₅₀ ≈1.3–5.4 nmol/L).

Pharmacokinetics

  • Oral bioavailability high; peak levels ~1–1.5 h post‑dose.
  • Long elimination half‑life (38–54 h) supports once‑weekly dosing.
  • Mainly renally excreted; minimal hepatic metabolism.

Pharmacodynamics

  • Sustains ~70–80% DPP‑4 inhibition for a week.
  • Phase 2/3 trials show HbA₁c reductions of ~0.5–1.0%.
  • Weight‑neutral, low hypoglycemia risk when used alone.

Clinical Efficacy & Safety

  • Monotherapy: dose‑dependent HbA₁c reduction similar to daily DPP‑4 inhibitors.
  • Phase 3 trials show non‑inferiority versus alogliptin; good tolerability.
  • Add‑on to insulin: ~0.63% greater HbA₁c reduction without severe hypoglycemia.
  • Pilot studies: increased adiponectin; no endothelial compromise.
  • Side effects: mild nasopharyngitis, headache, upper respiratory symptoms.

Clinical Implications

  • Once‑weekly dosing boosts adherence, especially in low‑resource areas.
  • Safe for diverse populations due to weight neutrality and low hypoglycemia risk.
  • Effective as adjunct therapy with insulin.

Precautions & Dosing

  • No dose adjustment in mild/moderate hepatic impairment.
  • Renal impairment: dose reductions per eGFR recommendations.
  • Use caution with insulin or sulfonylureas to avoid hypoglycemia.

Safety Profile and Complications of Trelagliptin

Introduction

Trelagliptin is generally well tolerated, but distinguishing common side effects from rare serious complications is essential.

1. Hypoglycemia

  • Monotherapy: low risk due to glucose‑dependent mechanism.
  • Combined therapy: risk increases with sulfonylureas or insulin; adjust doses accordingly.

2. Pancreatitis

  • Meta‑analyses show slight increase in acute pancreatitis risk (OR ~1.7).
  • Rare cases (~0.3%) in clinical trials.
  • Discontinue drug if pancreatitis suspected.

3. Bullous Pemphigoid

  • Possible 2–4× increased risk, particularly in people >70 years.
  • Discontinue if suspected; refer to dermatology.

4. Arthralgia

  • Severe joint pain reported; typically resolves after stopping drug.

5. Hypersensitivity

  • Rare angioedema, urticaria, anaphylaxis, especially in first 3 months.
  • Discontinue immediately; manage supportively.

6. Heart Failure

  • Saxagliptin and alogliptin showed heart failure risk, but no strong signal for Trelagliptin.
  • Monitor in heart disease patients.

Other Observations

  • Renal impairment: no major issues, but dose adjustments may be needed.
  • Gallbladder events: slightly increased in meta‑analyses.

Summary & Abbreviations

Summary: Trelagliptin is a once‑weekly oral DPP‑4 inhibitor offering simplified therapy, sustained glycemic control, and strong safety. It reduces pill burden, enhances adherence, and lowers complication risk. Rare but serious effects—pancreatitis, arthralgia, bullous pemphigoid, and hypersensitivity—require vigilance. While care is needed when combined with insulin or sulfonylureas or in comorbid conditions, the drug’s convenience and tolerability make it a promising option in diabetes management and public health.

Abbreviations:
DPP‑4 = dipeptidyl peptidase‑4 | GLP‑1 = glucagon‑like peptide‑1 | GIP = glucose‑dependent insulinotropic polypeptide | T2DM = type 2 diabetes mellitus | HbA1c = glycated hemoglobin | eGFR = estimated glomerular filtration rate.


References

  1. Seino Y, Kuwata H, Yabe D. Incretin-based drugs for type 2 diabetes: Focus on Takeda's trelagliptin and alogliptin. Expert Opin Pharmacother. 2015;16(16):2583–2596.
  2. Yabe D, Seino Y. DPP-4 inhibitors – their potential in the treatment of type 2 diabetes. Expert Opin Investig Drugs. 2011;20(3):343–360.
  3. Yasuda N, Inoue T, Nagakura T, et al. Trelagliptin, a novel once-weekly oral DPP-4 inhibitor: preclinical and clinical pharmacology. Diabetes Obes Metab. 2016;18(6):627–634.
  4. Monami M, Dicembrini I, Mannucci E. Dipeptidyl peptidase-4 inhibitors and pancreatitis risk: a meta-analysis. Diabetes Obes Metab. 2014;16(1):48–56.
  5. Singh S, Chang HY, Richards TM, et al. GLP-1 therapies and risk of acute pancreatitis. JAMA Intern Med. 2013;173(7):534–539.
  6. Ujiie T, Muramatsu K, Ozeki T, et al. DPP-4 inhibitors and bullous pemphigoid: a disproportionality analysis. Br J Dermatol. 2020;183(6):1121–1123.
  7. US FDA. Drug Safety Communication: DPP-4 inhibitors may cause severe joint pain. 2015.
  8. Scirica BM, Bhatt DL, Braunwald E, et al. Saxagliptin and cardiovascular outcomes in T2DM. N Engl J Med. 2013;369(14):1317–1326.
  9. White WB, Cannon CP, Heller SR, et al. Alogliptin after acute coronary syndrome. N Engl J Med. 2013;369(14):1327–1335.
  10. Yamada Y, Nishida T, Yamada Y, et al. Once-weekly trelagliptin in Japanese patients: phase III trial. Diabetes Obes Metab. 2016;18(3):249–257.
  11. Zuventus Healthcare Ltd. Efficacy and safety of once-weekly Trelagliptin vs vildagliptin in Indian patients. 2025.
  12. American Diabetes Association. Standards of Medical Care in Diabetes—2024. Diabetes Care. 2024;47(Suppl 1):S1–S207.

Tuesday, August 13, 2019

SOP - Hip Circumference


Hip circumference measurements are taken in some sites as an expanded option to measure overweight and obesity.


To take hip circumference measurements we need : 
  • constant tension tape (for example, Figure Finder Tape Measure)
  • pen/pencil
  • chair or coat stand for participant's to place their clothes.

A private area is necessary for this measurement. This could be a separate room, or an area that has been screened off from other people within the household. Hip measurements are taken immediately after waist circumferences.
  • This measurement should be taken without clothing, that is, directly over the skin.
  • If this is not possible, the measurement may be taken over light clothing (Must not be over thick or bulky clothing. This type of clothing must be removed)

This measurement should be taken:
  • with the arms relaxed at the sides
  • at the maximum circumference over the buttocks

Steps of measurement:
  1. Stand to the side of the participant, and ask them to help wrap the tape around themselves.
  2. Position the measuring tape around the maximum circumference of the buttocks.
  3. Ask the participant to: 
    • stand with their feet together with weight evenly distributed over both feet;
    • hold their arms relaxed at the sides.Check that the tape position is horizontal all around the body and snug without constricting.
  4. Measure hip circumference and read the measurement at the level of the tape to the nearest 0.1 cm.
  5. Record the measurement on the participant’s instrument.

SOP - mid upper arm circumference (MUAC)

  • The major determinants of MUAC are muscle and subcutaneous fat, both important determinants of survival in malnutrition and starvation. 
  • MUAC is less affected than weight and height based indices (e.g. Body Mass Index) by accumulation of fluid (i.e. nutritional oedema, periorbital oedema and ascites). 
  • So MUAC is a good predictor of mortality. 
  • It is recommended for identifying young children with, or at risk of, severe acute malnutrition and adults with acute energy deficiency.
  • In children between 6-59 months old, MUAC <110 mm indicates severe acute malnutrition and is recommended as a criterion for admission to therapeutic feeding programmes. 
  • Values between 110 and 120/125 mm indicate moderate malnutrition. 
  • Values below 250 mm in adults indicate severe wasting. 
  • (Note that MUAC is not sensitive enough to routinely monitor growth at young child clinics)








SOP

It's been quite a while since I posted something on my blog. Today while cleaning up the junk accumulated on my hard drive I came across several useful articles that I had prepared during my PG- ship.

SOP or standard operating procedures.

Sharing here are some of the articles that I found useful for public health purposes.


  1. mid upper arm circumference 
  2. waist circumference 
  3. hip circumference 
  4. height
  5. weight
  6. pallor




Monday, October 9, 2017

ECG monitoring using mobile device - when engineering met medicine

Innovativeness and creativity has always been a part of science. In this ever developing world, Science has made our lives easier. With every passing day a new development strikes the market and leaves it's imprint behind.

Mobile Technology has affected every aspect of the human life all over the world. Not only has mobile technology made connectivity easier, it has also positively impacted Healthcare services. In this regard and new development that caught my attention in recent times was the use of a smart phone to monitor ECG.

I came across such device on a Facebook Post. The interface uses ECG leads connected on the chest wall of the patient and transmitting data via cable directly to the mobile device. Once connected, an app installed in the mobile can recognize the electrical activity and display the graph. it can be used for continuous monitoring and also a graph can be printed. The best part of the system is that it can be used by Healthcare providers in Periphery (like in Sub Center or PHC) and the information can be transmitted to a higher setup.
In this manner even a health worker who has been trained to connect the leads on the patient's chest and run the app on mobile can take out an ECG from a patient who complains of cardiac or similar symptoms within moments. The data thus obtained can be analysed by doctor positioned more centrally and the health worker may be guided to take the best course of action which he may be unable to take himself otherwise.

For example, a patient visiting a sub Center located in a remote village complains of sudden onset chest pain. ECG taken out by the health worker may be immediately sent to the higher center to the consultant whereby a diagnosis of Acute Myocardial Infarction is suspected. Accordingly the health worker can be guided to provide the immediate care(like Morphine, Oxygen, Nitrate, Aspirin) and shift the patient as early as possible to a better equipped center for further management thus improving the chances of survival of the patient and bringing down the cost of therapy as well. This system may also help in avoiding unnecessary referrals.





Monday, October 31, 2016

People Who Travel Alone Are More Intelligent

A study by British Psychological Society revealed that people who experience solitude and who like to travel alone are more intelligent than others. They also concluded that, "lower life satisfaction with more frequent socialization with friends”, leads to an intelligent life.

The study was related to "savanna theory of happiness" according to which less socialising is equal to more intelligence and happiness.

They compared more rural living to how ancestors once traveled in close-knit, smaller tribes. Basically the lifestyles of hunter-gatherer tribes have formed the evolutionary foundation for what makes people happy now.

It was thus concluded that, for the average person, living in a smaller town and actively socializing with friends is key to happiness. However, for a highly intelligent person it was quite the opposite.

It was also observed that, smarter people try to spend time alone by taking days off to travel alone.

They contemplate on life and come back with some richer experiences.