51
|
Nirantharakumar K, Mohammed N, Toulis KA, Thomas GN, Narendran P. Clinically meaningful and lasting HbA 1c improvement rarely occurs after 5 years of type 1 diabetes: an argument for early, targeted and aggressive intervention following diagnosis. Diabetologia 2018; 61:1064-1070. [PMID: 29478098 PMCID: PMC6448997 DOI: 10.1007/s00125-018-4574-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/20/2017] [Indexed: 01/01/2023]
Abstract
AIMS/HYPOTHESIS Our objectives were to explore whether the phenomenon of HbA1c 'tracking' occurs in individuals with type 1 diabetes, how long after diagnosis does tracking take to stabilise, and whether there is an effect of sex and age at diagnosis on tracking. METHODS A total of 4525 individuals diagnosed with type 1 diabetes between 1 January 1995 and 1 May 2015 were identified from The Health Improvement Network (THIN) database. Mixed models were applied to assess the variability of HbA1c levels over time with random effects on general practices (primary care units) and individuals within practices. RESULTS 4525 individuals diagnosed with type 1 diabetes were identified in THIN over the study period. The greatest difference in mean HbA1c measurement (-7.0 [95% CI -8.0, -6.1] mmol/mol [0.6%]) was seen when comparing measurements made immediately after diagnosis (0-1 year since diagnosis) with those at 10 or more years (the reference category). The mean difference in HbA1c for the successive periods compared with 10 or more years after diagnosis declined and was no longer statistically significant after 5 years. In the stratified analysis using sex and age group there was considerable heterogeneity with adult onset type 1 diabetes appearing to track earlier and at a lower mean HbA1c. CONCLUSIONS/INTERPRETATION In individuals with type 1 diabetes, glycaemic control measured by HbA1c settles onto a long-term 'track' and this occurs on average by 5 years following diagnosis. Age at diagnosis modifies both the rate at which individuals settle into their track and the absolute HbA1c tracking level for the next 10 years.
Collapse
Affiliation(s)
- Krishnarajah Nirantharakumar
- Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Public Health, Epidemiology and Biostatistics, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Nuredin Mohammed
- Public Health, Epidemiology and Biostatistics, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Konstantinos A Toulis
- Public Health, Epidemiology and Biostatistics, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - G Neil Thomas
- Public Health, Epidemiology and Biostatistics, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Parth Narendran
- Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
- Institute of Immunology and Immunotherapy, Research College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| |
Collapse
|
52
|
Gallwitz B. The Cardiovascular Benefits Associated with the Use of Sodium-Glucose Cotransporter 2 Inhibitors - Real-World Data. EUROPEAN ENDOCRINOLOGY 2018; 14:17-23. [PMID: 29922347 PMCID: PMC5954590 DOI: 10.17925/ee.2018.14.1.17] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 03/14/2018] [Indexed: 12/20/2022]
Abstract
Type 2 diabetes (T2D) is associated with numerous comorbidities that significantly reduce quality of life, increase mortality and complicate treatment decisions. In a recent cardiovascular outcomes trial, Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG OUTCOME), the sodium-glucose cotransporter 2 (SGLT2) inhibitor empagliflozin was shown to reduce cardiovascular (CV) mortality and heart failure in high-risk patients with T2D with a previous CV event or with established CV disease (CVD). Recently published data from the Canagliflozin Cardiovascular Assessment Study (CANVAS-PROGRAM) study suggested that the cardiovascular benefits of empagliflozin are also seen with the SGLT2-inhibitor canagliflozin, indicating a class effect of SGLT2 inhibitors. Evidence for a class effect has also been shown by meta-analyses and real-world studies, including the Comparative Effectiveness of Cardiovascular Outcomes in New Users of SGLT-2 Inhibitors (CVD-REAL) and The Health Improvement Network (THIN) databases. These findings also suggest the results of EMPA-REG OUTCOME can be applied to patients with T2D with a broader CV risk profile, including people at low risk of CVD.
Collapse
Affiliation(s)
- Baptist Gallwitz
- Medizinische Klinik IV, University of Tübingen, Tübingen, Germany
| |
Collapse
|
53
|
Toulis KA, Bilezikian JP, Thomas GN, Hanif W, Kotsa K, Thayakaran R, Keerthy D, Tahrani AA, Nirantharakumar K. Initiation of dapagliflozin and treatment-emergent fractures. Diabetes Obes Metab 2018; 20:1070-1074. [PMID: 29193543 DOI: 10.1111/dom.13176] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 11/06/2017] [Accepted: 11/25/2017] [Indexed: 01/10/2023]
Abstract
An increase in fracture risk has been reported in patients with type 2 diabetes mellitus (T2DM) treated with canagliflozin, possibly mediated by effects induced by all members of the sodium-glucose co-transporter-2 (SGLT2) inhibitor class. It is unclear whether initiation of dapagliflozin is followed by an increase in the risk of fracture; therefore, we performed a population-based, open cohort study (from January 2013 to January 2016) using The Health Improvement Network (THIN). A total of 22 618 people with T2DM (4548 exposed to dapagliflozin and 18 070 receiving standard antidiabetic treatment, matched for age, sex, body mass index and diabetes duration) with no history of fractures at baseline were included. The primary outcome was the occurrence of any fragility fracture (hip, spine, wrist) during the observation period. Risk of any fracture served as a secondary outcome. Adjusted hazard rate ratios (HRs) with 95% confidence intervals (CIs) were calculated using Cox regression. A total of 289 fractures (132 fragility fractures) were recorded. No difference in the risk of fragility fracture was detected between participants prescribed dapagliflozin and matched control participants (crude HR 0.90, 95% CI 0.59-1.39, P = .645; adjusted HR 0.87, 95% CI 0.56-1.35, P = .531). Similarly, no difference in the risk of any fracture was detected (adjusted HR 0.89, 95% CI 0.66-1.20; P = .427). Sensitivity analyses limited to the subset of the population at high risk of fracture produced similar results; thus, there was no evidence to suggest an increase in the risk of treatment-emergent fractures in patients with T2DM who initiated treatment with dapagliflozin.
Collapse
Affiliation(s)
- Konstantinos A Toulis
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, 424 General Military Hospital, Thessaloniki, Greece
| | - John P Bilezikian
- Metabolic Bone Diseases Unit, Division of Endocrinology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York
| | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Wasim Hanif
- Diabetes Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Kalliopi Kotsa
- First Department of Internal Medicine, Division of Endocrinology & Diabetes Center, Aristotle University, Thessaloniki, Greece
| | - Rasiah Thayakaran
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Deepiksana Keerthy
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Diabetes and Endocrinology, Birmingham Heartlands Hospital, Birmingham B15 2TT, UK
| | | |
Collapse
|
54
|
Affiliation(s)
- Robert Guthrie
- Emergency Medicine, The Ohio State University, Dublin, OH, USA
| |
Collapse
|
55
|
Esteban-Jiménez O, Navarro-Pemán C, Urieta-González L. Seguridad de los iSGLT-2. Revisión de las reacciones adversas notificadas a nivel nacional. Semergen 2018; 44:23-29. [DOI: 10.1016/j.semerg.2017.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 08/06/2017] [Accepted: 10/19/2017] [Indexed: 12/14/2022]
|
56
|
Scorsone A, Saura G, Fleres M, Spano L, Aiello V, Brancato D, Di Noto A, Provenzano F, Provenzano V. Efficacy and Renal Safety of Dapagliflozin in Patients with Type 2 Diabetes Mellitus Also Receiving Metformin: A Real-Life Experience. J Diabetes Res 2018; 2018:8501418. [PMID: 29854825 PMCID: PMC5960527 DOI: 10.1155/2018/8501418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 03/05/2018] [Accepted: 03/13/2018] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION This study aimed at evaluating the efficacy and safety of dapagliflozin in patients with type 2 diabetes (T2D) who also received metformin in clinical practice in Italy. METHODS This was a retrospective observational study and it included data from patients who received dapagliflozin 10 mg once daily in conjunction with metformin for 12 months (DAPA + MET). In those with inadequate glycemic control, insulin or glimepiride was added after 30 days (DAPA + MET + other glucose-lowering drugs). Efficacy assessments included glycosylated hemoglobin (HbA1c) levels at 6 and 12 months, as well as body mass index (BMI) and lipid parameters at 12 months. Safety was also assessed. RESULTS Data on 66 patients were included. In both groups, HbA1c was significantly reduced at 6 and 12 months compared with baseline and significant reductions in HbA1c were observed at 12 months compared with 6 months. Over the 12-month treatment period, dapagliflozin significantly reduced BMI in both groups. No significant changes in lipid parameters were observed in either group and no detrimental effects on renal function were detected. CONCLUSIONS Dapagliflozin is effective and safe in patients with T2D also receiving metformin. Glycemic control was already achieved with dapagliflozin + metformin, and add-on therapy was not associated with further improvements.
Collapse
Affiliation(s)
- Alessandro Scorsone
- Regional Referral Centre for Insulin Pump Implantation and Diabetes, Civic Hospital, Partinico, Palermo, Italy
| | - Gabriella Saura
- Regional Referral Centre for Insulin Pump Implantation and Diabetes, Civic Hospital, Partinico, Palermo, Italy
| | - Mattia Fleres
- Regional Referral Centre for Insulin Pump Implantation and Diabetes, Civic Hospital, Partinico, Palermo, Italy
| | - Lucia Spano
- Regional Referral Centre for Insulin Pump Implantation and Diabetes, Civic Hospital, Partinico, Palermo, Italy
| | - Vito Aiello
- Regional Referral Centre for Insulin Pump Implantation and Diabetes, Civic Hospital, Partinico, Palermo, Italy
| | - Davide Brancato
- Regional Referral Centre for Insulin Pump Implantation and Diabetes, Civic Hospital, Partinico, Palermo, Italy
| | - Anna Di Noto
- Regional Referral Centre for Insulin Pump Implantation and Diabetes, Civic Hospital, Partinico, Palermo, Italy
| | | | - Vincenzo Provenzano
- Regional Referral Centre for Insulin Pump Implantation and Diabetes, Civic Hospital, Partinico, Palermo, Italy
| |
Collapse
|
57
|
Abstract
Over the past 30 years there have been many complementary therapies developed to achieve glycemic control and have an impact on cardiovascular outcomes, as well as reduce the risk of microvascular disease. The 2 most notable new entries have been the sodium-glucose cotransporter 2 (SGLT2) inhibitors and the glucagon-like peptide-1 (GLP-1) agonists. Both these classes of agents have demonstrated reductions in cardiovascular event rates as well as reductions in blood pressure and weight. Moreover, while both have demonstrated a benefit in slowing nephropathy progression, the SGLT2 inhibitors appear to have a significantly greater effect compared with the GLP-1 agents. There is an ongoing trial specifically powered for renal disease progression, CREDENCE (Evaluation of the Effects of Canagliflozin on Renal and Cardiovascular Outcomes in Participants With Diabetic Nephropathy). Additionally, there are 2 other classes of agents being tested to slow nephropathy progression, a selective endothelin-1 receptor antagonist, atrasantan, in the SONAR (Study of Diabetic Nephropathy With Atrasentan) trial and a nonsteroidal mineralocorticoid receptor antagonist, finerenone, in the FIDELIO (Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus) trial. These and other studies are discussed.
Collapse
Affiliation(s)
- David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - George L Bakris
- Department of Medicine, American Society of Hypertension Comprehensive Hypertension Center, University of Chicago Medicine, Chicago, Illinois, USA
| |
Collapse
|
58
|
Schernthaner G, Khunti K, Lotan C, Burnier M, Drexel H, Prázný M. Relevance of positive cardiovascular outcome trial results in clinical practice: perspectives from the Academy for Cardiovascular Risk, Outcomes and Safety Studies in Type 2 Diabetes (ACROSS T2D). Ther Clin Risk Manag 2017; 13:1569-1576. [PMID: 29276388 PMCID: PMC5733371 DOI: 10.2147/tcrm.s144362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Type 2 diabetes (T2D) imposes a substantial disease burden, predominantly from cardiovascular disease (CVD), which accounts for >50% of deaths in this population and leads to a 12-year reduction in the life expectancy of a 60-year-old male patient with T2D and CVD compared with the general population. The results from mandatory cardiovascular outcome trials (CVOTs) are therefore of great interest in the field. The Academy for Cardiovascular Risk, Outcomes and Safety Studies in Type 2 Diabetes meeting program aims to bring together experts from several associated disciplines to provide fair and balanced resources for those involved in the management of patients with T2D. This publication represents the opinions of the faculty on the key learnings from the meeting held in Vienna in the spring of 2017. In particular, we detail how data from the EMPA-REG OUTCOME® [cardiovascular outcomes trial of empagliflozin] and Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER®) (liraglutide) CVOTs can be practically interpreted across clinical specialities. It is hoped that this translation of CVOT data will achieve a dual treatment paradigm for the management of both raised glucose levels and CV risk in patients with T2D.
Collapse
Affiliation(s)
| | - Kamlesh Khunti
- Diabetes Research Centre, Leicester General Hospital, Leicester, UK
| | - Chaim Lotan
- Cardiovascular Division, Hadassah Medical Centre, Jerusalem, Israel
| | - Michel Burnier
- Division of Nephrology and Hypertension Consultation, University Hospital of Lausanne, Lausanne, Switzerland
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment, Feldkirch, Austria
| | | |
Collapse
|
59
|
Fadini GP, Zatti G, Consoli A, Bonora E, Sesti G, Avogaro A. Rationale and design of the DARWIN-T2D (DApagliflozin Real World evIdeNce in Type 2 Diabetes): A multicenter retrospective nationwide Italian study and crowdsourcing opportunity. Nutr Metab Cardiovasc Dis 2017; 27:1089-1097. [PMID: 28967594 DOI: 10.1016/j.numecd.2017.08.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/26/2017] [Accepted: 08/01/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Randomized controlled trials (RCTs) in the field of diabetes have limitations inherent to the fact that design, setting, and patient characteristics may be poorly transferrable to clinical practice. Thus, evidence from studies using routinely accumulated clinical data are increasingly valued. AIMS We herein describe rationale and design of the DARWIN-T2D (DApagliflozin Real World evIdeNce in Type 2 Diabetes), a multicenter retrospective nationwide study conducted at 50 specialist outpatient clinics in Italy and promoted by the Italian Diabetes Society. DATA SYNTHESIS The primary objective of the study is to describe the baseline clinical characteristics (particularly HbA1c) of patients initiated on dapagliflozin from marketing authorization approval to the end of 2016. Secondary and exploratory objectives will evaluate the changes in glycaemic and extraglycaemic efficacy parameters after initiation of dapagliflozin or after initiation of comparator glucose lowering medications (DPP-4 inhibitors, gliclazide extended release, and long-acting GLP-1 receptor agonists). An automated software will extract relevant data from the same electronic chart system at all centres, thereby minimizing data treatment and human intervention. CONCLUSION The study is expected to collect an enormous dataset of information on dapagliflozin- and comparator-using patients. After study completion, the Italian Diabetes Society will launch an open crowdsourcing call on the DARWIN-T2D database, challenging diabetes researchers to apply their ideas and approaches to address new unmet needs and knowledge gaps in diabetes. We believe this will move DARWIN-T2D to the next generation of real world studies.
Collapse
Affiliation(s)
- G P Fadini
- Department of Medicine, University of Padova, 35128 Padova, Italy.
| | - G Zatti
- Department of Medicine, University of Padova, 35128 Padova, Italy
| | - A Consoli
- Department of Medicine and Aging Science, "G. D'Annunzio" University of Chieti, 68100 Chieti, Italy
| | - E Bonora
- Department of Medicine, University of Verona, 37154 Verona, Italy
| | - G Sesti
- Department of Medical and Surgical Sciences, "Magna Graecia" University of Catanzaro, 88100 Catanzaro, Italy
| | - A Avogaro
- Department of Medicine, University of Padova, 35128 Padova, Italy
| |
Collapse
|
60
|
Saleem F. Dapagliflozin: Cardiovascular Safety and Benefits in Type 2 Diabetes Mellitus. Cureus 2017; 9:e1751. [PMID: 29226041 PMCID: PMC5716679 DOI: 10.7759/cureus.1751] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/05/2017] [Indexed: 12/13/2022] Open
Abstract
Sodium-glucose co-transporter 2 inhibitors (SGLT2is) such as dapagliflozin, canagliflozin, and empagliflozin, are a promising new therapy in the treatment of type 2 diabetes mellitus (T2DM). SGLT2is can effectively reduce hyperglycemia thus improving glycemic control and they offer some beneficial effects on the cardiovascular (CV) system which can benefit patients with heart failure in addition toT2DM. The United States Food and Drug Administration requires new diabetes mellitus therapies to show a CV safety profile. Empagliflozin was the first SGLT2i that, when added to the standard of care for patients withT2DM at high risk for CV events, showed improved CV outcomes including reduced deaths from CV causes. Evidence also exists in favor of dapagliflozin for use in patients with T2DM with CV risk factors and heart failure. This review focuses on the effects, safety, and benefits of dapagliflozin on the CV system. Clinical trials have shown that dapagliflozin improves glycemic control without variation. It is safe and well-tolerated in the general population including older patients and those with high-risk CV factors or preexisting CV disease. There may be a renal protective role by an unknown mechanism. Dapagliflozin also lowers blood pressure due to its natriuresis effect. It improves levels of visceral fat and reduces body weight, and thus ameliorates metabolic syndrome. Dapagliflozin reduces oxidative stress and may delay atherosclerosis. Recent findings indicate SGLT2is may also reduce the atrial natriuretic peptide levels. Additional trials are required to validate these benefits and further evaluate if these are class effects. Trials such as DECLARE-TIMI58 are ongoing to evaluate the CV outcomes of dapagliflozin. More research is needed to design better antihyperglycemic regimes with clinical benefits in addition to good glycemic control.
Collapse
Affiliation(s)
- Fatima Saleem
- Internal medicine, King Edward Medical University Lahore, Pakistan
| |
Collapse
|
61
|
The Landscape of Glucose-Lowering Therapy and Cardiovascular Outcomes: From Barren Land to Metropolis. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9257930. [PMID: 29270438 PMCID: PMC5705897 DOI: 10.1155/2017/9257930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/24/2017] [Accepted: 09/14/2017] [Indexed: 12/11/2022]
Abstract
The choice of glucose-lowering therapy (GLT) has expanded to include 11 different classes in addition to insulin. Since the 2008 Food and Drug Administration guidance for industry and mandate of demonstrating cardiovascular (CV) safety prior to any new drug approval, there were several trials primarily conducted to establish that goal. Some had neutral effects, while there were positively beneficial outcomes with more recent studies. Hospitalization for congestive heart failure has also been a heterogeneous finding among the different classes of GLT, with drug outcomes ranging from risky to beneficial. The current review selectively focuses on the evidence for CV outcomes for each class of GLT and summarizes the existing guidelines with regard to these drugs in heart disease. Moreover, it illustrates the dynamic status in the development of evidence. Finally, the review enables healthcare providers to formulate a plan for hypoglycemic therapy which will optimize CV health, in a patient-centered manner.
Collapse
|