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Monami M, Dicembrini I, Mannucci E. Effects of SGLT-2 inhibitors on mortality and cardiovascular events: a comprehensive meta-analysis of randomized controlled trials. Acta Diabetol 2017; 54:19-36. [PMID: 27488726 DOI: 10.1007/s00592-016-0892-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 07/21/2016] [Indexed: 12/23/2022]
Abstract
AIMS EMPAREG OUTCOME study showed a reduction in cardiovascular events in patients treated with the sodium-glucose transporter 2 inhibitor (SGLT2i) empagliflozin, as compared to placebo. Other drugs of the same class are currently been investigated for cardiovascular outcomes. In the meanwhile, a re-analysis of data collected in available studies can add relevant insight. METHODS A MEDLINE search for SGLT-2 inhibitors (dapagliflozin, empagliflozin, canagliflozin, ipragliflozin, ertugliflozin, luseogliflozin) was performed, collecting all randomized trials up to November 16, 2015. All trials with a duration of treatment ≥12 weeks, enrolling patients with type 2 diabetes, comparing a SGLT2i with placebo or other comparators were included. The principal outcome was the effect of SGLT2i on all-cause and cardiovascular mortality. Secondary endpoints were myocardial infarction and stroke. Mantel-Haenszel odds ratio with 95 % confidence interval (MH-OR) was calculated. RESULTS A total of 71 trials were included (31,199 and 16,088 patients in SGLT2i and comparator groups). Treatment with SGLT2i was associated with a significant reduction in all-cause mortality (MH-OR 0.70 [0.59-0.83], p < 0.001), cardiovascular mortality (MH-OR 0.43 [0.36-0.53], p < 0.001), and myocardial infarction (MH-OR 0.77 [0.63-0.94], p < 0.01), but not stroke (MH-OR 1.09 [0.86-1.38], p = 0.50), with no apparent difference across molecules (after excluding cardiovascular outcome trials). CONCLUSIONS Available data suggest that the beneficial action observed with empagliflozin on all-cause and cardiovascular mortality in EMPAREG OUTCOME study is a class effect. The present meta-analysis showed a significantly reduction in myocardial infarction, with no increased risk of stroke.
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Affiliation(s)
- Matteo Monami
- Diabetology, Azienda Ospedaliero-Universitaria Careggi, Careggi Teaching Hospital, University of Florence, Via delle Oblate 4, 50141, Florence, Italy.
| | - Ilaria Dicembrini
- Diabetology, Azienda Ospedaliero-Universitaria Careggi, Careggi Teaching Hospital, University of Florence, Via delle Oblate 4, 50141, Florence, Italy
| | - Edoardo Mannucci
- Diabetology, Azienda Ospedaliero-Universitaria Careggi, Careggi Teaching Hospital, University of Florence, Via delle Oblate 4, 50141, Florence, Italy
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252
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Lundkvist P, Sjöström CD, Amini S, Pereira MJ, Johnsson E, Eriksson JW. Dapagliflozin once-daily and exenatide once-weekly dual therapy: A 24-week randomized, placebo-controlled, phase II study examining effects on body weight and prediabetes in obese adults without diabetes. Diabetes Obes Metab 2017; 19:49-60. [PMID: 27550386 PMCID: PMC5215525 DOI: 10.1111/dom.12779] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 08/18/2016] [Accepted: 08/18/2016] [Indexed: 12/13/2022]
Abstract
AIMS To explore the effects of dual therapy with dapagliflozin and exenatide on body weight, body composition, glycaemic variables and systolic blood pressure (SBP) in obese adults without diabetes. MATERIALS AND METHODS In this single-centre, double-blind trial, we randomized 50 obese adults without diabetes (aged 18-70 years; body mass index 30-45 kg/m2 ) to oral dapagliflozin 10 mg once daily plus subcutaneous long-acting exenatide 2 mg once weekly or placebo. MRI was used to assess change in body composition. Participants were instructed to follow a balanced diet and exercise moderately. RESULTS Of 25 dapagliflozin/exenatide- and 25 placebo-treated participants, 23 (92.0%) and 20 (80.0%) completed 24 weeks of treatment, respectively. At baseline, the mean participant age was 52 years, 61% were female, the mean body weight was 104.6 kg, and 73.5% of participants had prediabetes (impaired fasting glucose or impaired glucose tolerance). After 24 weeks, for dapagliflozin/exenatide versus placebo: the difference in body weight change was -4.13 kg (95% confidence interval -6.44, -1.81; P < .001), which was mostly attributable to adipose tissue reduction without lean tissue change; 36.0% versus 4.2% of participants achieved ≥5% body weight loss, respectively; and prediabetes was less frequent with active treatment (34.8% vs 85.0%, respectively; P < .01). The difference in SBP change for dapagliflozin/exenatide versus placebo was -6.7 mm Hg. As expected, nausea and injection-site reactions were more frequent with dapagliflozin/exenatide than with placebo. Only two and three participants, respectively, discontinued because of adverse events. CONCLUSIONS Compared with placebo, dapagliflozin/exenatide dual therapy reduced body weight, frequency of prediabetes and SBP over 24 weeks and was well tolerated in obese adults without diabetes.
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Affiliation(s)
- Per Lundkvist
- Department of Medical SciencesUppsala UniversityUppsalaSweden
| | | | - Sam Amini
- Department of Medical SciencesUppsala UniversityUppsalaSweden
| | | | | | - Jan W. Eriksson
- Department of Medical SciencesUppsala UniversityUppsalaSweden
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253
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Kalra S, Ghosh S, Aamir AH, Ahmed MT, Amin MF, Bajaj S, Baruah MP, Bulugahapitiya U, Das AK, Giri M, Gunatilake S, Mahar SA, Pathan MF, Qureshi NK, Raza SA, Sahay R, Shakya S, Shreshta D, Somasundaram N, Sumanatilleke M, Unnikrishnan AG, Wijesinghe AM. Safe and pragmatic use of sodium-glucose co-transporter 2 inhibitors in type 2 diabetes mellitus: South Asian Federation of Endocrine Societies consensus statement. Indian J Endocrinol Metab 2017; 21:210-230. [PMID: 28217523 PMCID: PMC5240067 DOI: 10.4103/2230-8210.196029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Diabetes prevalence shows a continuous increasing trend in South Asia. Although well-established treatment modalities exist for type 2 diabetes mellitus (T2DM) management, they are limited by their side effect profile. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) with their novel insulin-independent renal action provide improved glycemic control, supplemented by reduction in weight and blood pressure, and cardiovascular safety. Based on the clinical outcomes with SGLT2i in patients with T2DM, treatment strategies that make a "good clinical sense" are desirable. Considering the peculiar lifestyle, body types, dietary patterns (long duration religious fasts), and the hot climate of the South Asian population, a unanimous decision was taken to design specific, customized guidelines for T2DM treatment strategies in these regions. The panel met for a discussion three times so as to get a consensus for the guidelines, and only unanimous consensus was included. After careful consideration of the quality and strength of the available evidence, the executive summary of this consensus statement was developed based on the American Association of Clinical Endocrinologists/American College of Endocrinology protocol.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
| | - Sujoy Ghosh
- Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - A. H. Aamir
- Department of Endocrinology and Metabolic Diseases, Post Graduate Medical Institute, Hayatabad Medical Complex, Peshawar, Pakistan
| | - Md. Tofail Ahmed
- Department of Endocrinology, BIRDEM and Ibrahim Medical College, Dhaka, Bangladesh
| | - Mohammod Feroz Amin
- Department of Endocrinology, BIRDEM and Ibrahim Medical College, Dhaka, Bangladesh
| | - Sarita Bajaj
- Department of Medicine, MLN Medical College, Allahabad, Uttar Pradesh, India
| | - Manash P. Baruah
- Department of Endocrinology, Excel Centre Hospitals, Guwahati, Assam, India
| | | | - A. K. Das
- Department of Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Mimi Giri
- BP Koirala Institute of Health Sciences, Dharan, Nepal
| | - Sonali Gunatilake
- Department of Endocrinology, Colombo South Teaching Hospital, Colombo, Sri Lanka
| | - Saeed A. Mahar
- Department of Medicine, National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Md. Faruque Pathan
- Department of Endocrinology, BIRDEM and Ibrahim Medical College, Dhaka, Bangladesh
| | | | - S. Abbas Raza
- Department of Medicine, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Rakesh Sahay
- Department of Endocrinology, Osmania Medical College, Hyderabad, Telangana, India
| | - Santosh Shakya
- Diabetes, Thyroid and Endocrinology Care Centre, Kopundole, Nepal
| | - Dina Shreshta
- Department of Endocrinology, Norvic Hospital, Kathmandu, Nepal
| | - Noel Somasundaram
- Department of Endocrinology, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | | | - A. G. Unnikrishnan
- Department of Endocrinology, Chellaram Institute of Diabetes, Pune, Maharashtra, India
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Yu H, Woo VC. Emerging use of combination therapies for the management of type 2 diabetes - focus on saxagliptin and dapagliflozin. Diabetes Metab Syndr Obes 2017; 10:317-332. [PMID: 28769579 PMCID: PMC5533573 DOI: 10.2147/dmso.s117982] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
AIMS The aim of this article is to review the safety and efficacy data of dapagliflozin, saxagliptin, and their combination in the management of patients with type 2 diabetes. Evidence for the use of the single-tablet combination formulation is also presented. METHODS A nonsystematic literature review was performed using the Ovid, PubMed, and Google Scholar databases. RESULTS The addition of dapagliflozin/saxagliptin to metformin can lower mean hemoglobin A1c by as much as 1.47% and lead to weight loss of 0.5-2.0 kg. The risk of genital infections with combination therapy is lower than observed with dapagliflozin alone, suggestive of a protective effect. Adverse event risk at 52-week follow-up was not increased beyond that seen with either monotherapy. CONCLUSION Dapagliflozin/saxagliptin combination is generally well tolerated and is an effective tool in helping patients with diabetes improve glycemic control.
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Affiliation(s)
- Huan Yu
- Department of Medicine, Division of Endocrinology and Metabolism, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
- Correspondence: Huan Yu, Department of Medicine, Section of Endocrinology and Metabolism, Health Sciences Centre, University of Manitoba, 838-715 McDermot Avenue, Winnipeg, MB, Canada R3E 3P4, Tel +1 204 957 3218, Fax +1 204 943 3516, Email
| | - Vincent C Woo
- Department of Medicine, Division of Endocrinology and Metabolism, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
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Tanaka A, Node K. Emerging roles of sodium-glucose cotransporter 2 inhibitors in cardiology. J Cardiol 2016; 69:501-507. [PMID: 28043708 DOI: 10.1016/j.jjcc.2016.10.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 10/27/2016] [Indexed: 12/18/2022]
Abstract
The ultimate goal of treatment in people with diabetes mellitus is to prevent development of cardiovascular (CV) disease, resulting in prolongation of healthy life expectancy. Although impaired glycemic metabolism has a central role in its pathology, a number of studies have demonstrated that remedy for its imbalance cannot necessarily be accomplished as a therapeutic goal. A comprehensive medical approach against multi-factorial pathologies in diabetes, such as insulin resistance, obesity, hypertension, and dyslipidemia, in addition to diet and exercise therapy should be rather performed in the routine clinical setting. Along with such conceptual transition, what is required in anti-diabetes agents has also changed, and several anti-diabetes agents have been newly placed on the market in this decade. Such agents are required to undergo global pre- or post-marketing clinical trials assessing CV safety. A growing body of clinical evidence from those trials is now accumulating, and empagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor, has first demonstrated significant risk reduction, relative to placebo, in CV death, overall mortality, and hospitalization for worsened heart failure in high-risk patients with diabetes mellitus. An SGLT2 inhibitor is a unique glucose-lowering agent and at the same time has multifaceted effects on hemodynamic and metabolic parameters beyond glycemic control. A major mode of action of SGLT2 inhibitors appears to be 'glycosuria' and 'natriuresis,' leading to amelioration of systemic glycemic homeostasis and potential cardio-renal protection. However, the precise mechanisms by which SGLT2 inhibitors affect benefits on the CV systems are yet to be fully elucidated. Thus, although we are now facing several unanswered concerns lurking behind the successful trial, SGLT2 inhibitors surely play several important roles in high-quality management of not only diabetes, but also CV medicine. This review summarizes our current understandings and future perspectives of SGLT2 inhibitors in CV medicine.
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Affiliation(s)
- Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan.
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256
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Tang HL, Li DD, Zhang JJ, Hsu YH, Wang TS, Zhai SD, Song YQ. Lack of evidence for a harmful effect of sodium-glucose co-transporter 2 (SGLT2) inhibitors on fracture risk among type 2 diabetes patients: a network and cumulative meta-analysis of randomized controlled trials. Diabetes Obes Metab 2016; 18:1199-1206. [PMID: 27407013 DOI: 10.1111/dom.12742] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 07/06/2016] [Accepted: 07/08/2016] [Indexed: 01/10/2023]
Abstract
AIM To evaluate the comparative effects of sodium-glucose co-transporter 2 (SGLT2) inhibitors on risk of bone fracture in patients with type 2 diabetes mellitus (T2DM). METHODS PubMed, EMBASE, CENTRAL and ClinicalTrials.gov were systematically searched from inception to 27 January 2016 to identify randomized controlled trials (RCTs) reporting the outcome of fracture in patients with T2DM treated with SGLT2 inhibitors. Pairwise and network meta-analyses, as well as a cumulative meta-analysis, were performed to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS A total of 38 eligible RCTs (10 canagliflozin, 15 dapagliflozin and 13 empagliflozin) involving 30 384 patients, with follow-ups ranging from 24 to 160 weeks, were included. The fracture event rates were 1.59% in the SGLT2 inhibitor groups and 1.56% in the control groups. The incidence of fracture events was similar among these three SGLT2 inhibitor groups. Compared with placebo, canagliflozin (OR 1.15; 95% CI 0.71-1.88), dapagliflozin (OR 0.68; 95% CI 0.37-1.25) and empagliflozin (OR 0.93; 95% CI 0.74-1.18) were not significantly associated with an increased risk of fracture. Our cumulative meta-analysis indicated the robustness of the null findings with regard to SGLT2 inhibitors. CONCLUSIONS Our meta-analysis based on available RCT data does not support the harmful effect of SGLT2 inhibitors on fractures, although future safety monitoring from RCTs and real-world data with detailed information on bone health is warranted.
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Affiliation(s)
- H L Tang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, USA
- Center for Pharmacoepidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, USA
| | - D D Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - J J Zhang
- Division of Nephrology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Y H Hsu
- Hebrew Seniorlife Institute for Aging Research and Harvard Medical School, Boston, Massachusetts, USA
| | - T S Wang
- Department of Pharmacy Administration and Clinical Pharmacy, Peking University Health Science Center, Beijing, China
| | - S D Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Y Q Song
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, USA
- Center for Pharmacoepidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, USA
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Tang H, Zhang X, Zhang J, Li Y, Del Gobbo LC, Zhai S, Song Y. Elevated serum magnesium associated with SGLT2 inhibitor use in type 2 diabetes patients: a meta-analysis of randomised controlled trials. Diabetologia 2016; 59:2546-2551. [PMID: 27628105 DOI: 10.1007/s00125-016-4101-6] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 08/18/2016] [Indexed: 12/22/2022]
Abstract
AIMS/HYPOTHESIS By analysing available evidence from randomised controlled trials (RCTs), we aimed to examine whether and to what extent sodium-glucose cotransporter 2 (SGLT2) inhibitors affect serum electrolyte levels in type 2 diabetes patients. METHODS We searched PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov up to 24 May 2016 for published RCTs of SGLT2 inhibitors that reported changes in serum electrolyte levels. Weighted mean differences (WMD) between each SGLT2 inhibitor and placebo were calculated using a random-effects model. Dose-dependent relationships for each SGLT2 inhibitor were evaluated using meta-regression analysis. RESULTS Eighteen eligible RCTs, including 15,309 patients and four SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin and ipragliflozin) were evaluated. In patients without chronic kidney disease, each SGLT2 inhibitor significantly increased serum magnesium levels compared with placebo (canagliflozin: WMD 0.06 mmol/l for 100 mg and 0.09 mmol/l for 300 mg; dapagliflozin: WMD 0.1 mmol/l for 10 mg; empagliflozin: WMD 0.04 mmol/l for 10 mg and 0.07 mmol/l for 25 mg; and ipragliflozin: WMD 0.05 mmol/l for 50 mg). Canagliflozin increased serum magnesium in a linear dose-dependent manner (p = 0.10). Serum phosphate was significantly increased by dapagliflozin. Serum sodium appeared to significantly differ by SGLT2 inhibitor type. No significant changes in serum calcium and potassium were observed. Findings were robust after including trials involving patients with chronic kidney disease. CONCLUSIONS/INTERPRETATION SGLT2 inhibitors marginally increased serum magnesium levels in type 2 diabetes patients indicating a drug class effect. Further investigations are required to examine the clinical significance of elevated magnesium levels in individuals with type 2 diabetes.
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Affiliation(s)
- Huilin Tang
- Department of Pharmacy, Peking University Third Hospital, Beijing, People's Republic of China
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, 1050 Wishard Blvd, Indianapolis, IN, 46202, USA
- Center for Pharmacoepidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA
| | - Xi Zhang
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, 1050 Wishard Blvd, Indianapolis, IN, 46202, USA
- Center for Pharmacoepidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA
| | - Jingjing Zhang
- Division of Nephrology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Yufeng Li
- Department of Endocrinology, Beijing Pinggu Hospital, Beijing, People's Republic of China
| | - Liana C Del Gobbo
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, People's Republic of China
| | - Yiqing Song
- Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, 1050 Wishard Blvd, Indianapolis, IN, 46202, USA.
- Center for Pharmacoepidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA.
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Wilding J, Bailey C, Rigney U, Blak B, Beekman W, Emmas C. Glycated Hemoglobin, Body Weight and Blood Pressure in Type 2 Diabetes Patients Initiating Dapagliflozin Treatment in Primary Care: A Retrospective Study. Diabetes Ther 2016; 7:695-711. [PMID: 27585582 PMCID: PMC5118232 DOI: 10.1007/s13300-016-0193-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION The present study aimed to describe characteristics of patients with type 2 diabetes (T2D) in UK primary care initiated on dapagliflozin, post-dapagliflozin changes in glycated hemoglobin (HbA1c), body weight and blood pressure, and reasons for adding dapagliflozin to insulin. METHODS Retrospective study of patients with T2D in the Clinical Practice Research Datalink with first prescription for dapagliflozin. Patients were included in the study if they: (1) had a first prescription for dapagliflozin between November 2012 and September 2014; (2) had a Read code for T2D; (3) were registered with a practice for at least 6 months before starting dapagliflozin; and (4) remained registered for at least 3 months after initiation. A questionnaire ascertained reason(s) for adding dapagliflozin to insulin. RESULTS Dapagliflozin was most often used as triple therapy (27.7%), dual therapy with metformin (25.1%) or added to insulin (19.2%). Median therapy duration was 329 days [95% confidence interval (CI) 302-361]. Poor glycemic control was the reason for dapagliflozin initiation for 93.1% of insulin-treated patients. Avoiding increases in weight/body mass index and insulin resistance were the commonest reasons for selecting dapagliflozin versus intensifying insulin. HbA1c declined by mean of 9.7 mmol/mol (95% CI 8.5-10.9) (0.89%) 14-90 days after starting dapagliflozin, 10.2 mmol/mol (95% CI 8.9-11.5) (0.93%) after 91-180 days and 12.6 mmol/mol (95% CI 11.0-14.3) (1.16%) beyond 180 days. Weight declined by mean of 2.6 kg (95% CI 2.3-2.9) after 14-90 days, 4.3 kg (95% CI 3.8-4.7) after 91-180 days and 4.6 kg (95% CI 4.0-5.2) beyond 180 days. In patients with measurements between 14 and 90 days after starting dapagliflozin, systolic and diastolic blood pressure decreased by means of 4.5 (95% CI -5.8 to -3.2) and 2.0 (95% CI -2.9 to -1.2) mmHg, respectively from baseline. Similar reductions in systolic and diastolic blood pressure were observed after 91-180 days and when follow-up extended beyond 180 days. Results were consistent across subgroups. CONCLUSION HbA1c, body weight and blood pressure were reduced after initiation of dapagliflozin in patients with T2D in UK primary care and the changes were consistent with randomized clinical trials. FUNDING AstraZeneca.
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Affiliation(s)
- John Wilding
- Diabetes and Endocrinology Research Group, Institute of Ageing and Chronic Disease, Clinical Sciences Centre, University Hospital Aintree, Liverpool, UK.
| | | | - Una Rigney
- AstraZeneca, 600 Capability Green, Luton, UK
| | - Betina Blak
- AstraZeneca, 600 Capability Green, Luton, UK
| | - Wendy Beekman
- AstraZeneca, Louis Pasteurlaan 5, 2719 EE, Zoetermeer, The Netherlands
| | - Cathy Emmas
- AstraZeneca, 600 Capability Green, Luton, UK
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Tsimihodimos V, Filippatos TD, Elisaf MS. Effects of sodium-glucose co-transporter 2 inhibitors on metabolism: unanswered questions and controversies. Expert Opin Drug Metab Toxicol 2016; 13:399-408. [DOI: 10.1080/17425255.2017.1258055] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Vasilios Tsimihodimos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | | | - Moses S. Elisaf
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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Iwahashi Y, Hirose S, Nakajima S, Seo A, Takahashi T, Tamori Y. Evaluation of metabolic parameters and body composition in Japanese patients with type 2 diabetes mellitus who were administered tofogliflozin for 48 weeks. Diabetol Int 2016; 8:205-211. [PMID: 30603323 DOI: 10.1007/s13340-016-0295-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 10/26/2016] [Indexed: 01/10/2023]
Abstract
Sodium glucose cotransporter 2 inhibitors are unique antihyperglycemic agents that cause osmotic diuresis and calorie loss to urine. We previously reported that administration of tofogliflozin, a sodium glucose cotransporter 2 inhibitor, for 8 weeks decreased fat-free mass without affecting fat mass. We thus investigated the impact of tofogliflozin on metabolic parameters and body composition for 48 weeks in Japanese patients with type 2 diabetes mellitus. This single-arm open-label study enrolled 20 patients. Patients received tofogliflozin 20 mg once daily for 48 weeks. At week 48, changes in metabolic parameters and body composition from baseline were evaluated. Two patients discontinued administration due to adverse events during the first 8 weeks; however, no other adverse events occurred after that period. Seventeen patients completed the 48 weeks of administration of tofogliflodin. Body weight and body mass index decreased during the treatment period. Hemoglobin A1c decreased from 7.8% to 7.1%. The degree of improvement in hemoglobin A1c was correlated with body mass index, fat mass, and plasma glucose level at baseline. As for body composition, fat mass decreased without any change in fat-free mass (including total body water, extracellular water, and intracellular water). Red blood cell count and hematocrit increased, while the estimated glomerular filtration rate decreased. ALT and γ-GTP decreased and the decrease in γ-GTP was correlated with the loss of fat mass. In conclusion, our study clearly suggests that the body weight reduction caused by tofogliflozin administration for 48 weeks was almost entirely due to fat mass dissipation.
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Affiliation(s)
- Yasuyuki Iwahashi
- 1Division of Diabetes and Endocrinology, Department of Internal Medicine, Chibune General Hospital, 2-2-45, Tsukuda, Nishiyodogawa-ku, Osaka, 555-0001 Japan
| | - Sachie Hirose
- 1Division of Diabetes and Endocrinology, Department of Internal Medicine, Chibune General Hospital, 2-2-45, Tsukuda, Nishiyodogawa-ku, Osaka, 555-0001 Japan.,Present Address: Division of Endocrinology, Department of Internal Medicine, Osaka Gyomeikan Hospital, 5-4-8, Nishikujyo, Konohana-ku, Osaka, 554-0012 Japan
| | - Shinsuke Nakajima
- 2Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017 Japan
| | - Akane Seo
- 1Division of Diabetes and Endocrinology, Department of Internal Medicine, Chibune General Hospital, 2-2-45, Tsukuda, Nishiyodogawa-ku, Osaka, 555-0001 Japan
| | - Tetsuya Takahashi
- 1Division of Diabetes and Endocrinology, Department of Internal Medicine, Chibune General Hospital, 2-2-45, Tsukuda, Nishiyodogawa-ku, Osaka, 555-0001 Japan
| | - Yoshikazu Tamori
- 1Division of Diabetes and Endocrinology, Department of Internal Medicine, Chibune General Hospital, 2-2-45, Tsukuda, Nishiyodogawa-ku, Osaka, 555-0001 Japan.,2Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe, 650-0017 Japan
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Storgaard H, Gluud LL, Bennett C, Grøndahl MF, Christensen MB, Knop FK, Vilsbøll T. Benefits and Harms of Sodium-Glucose Co-Transporter 2 Inhibitors in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0166125. [PMID: 27835680 PMCID: PMC5106000 DOI: 10.1371/journal.pone.0166125] [Citation(s) in RCA: 162] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/24/2016] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Sodium-glucose co-transporter 2 inhibitors (SGLT2-i) are a novel drug class for the treatment of diabetes. We aimed at describing the maximal benefits and risks associated with SGLT2-i for patients with type 2 diabetes. DESIGN Systematic review and meta-analysis. DATA SOURCES AND STUDY SELECTION We included double-blinded, randomised controlled trials (RCTs) evaluating SGLT2-i administered in the highest approved therapeutic doses (canagliflozin 300 mg/day, dapagliflozin 10 mg/day, and empagliflozin 25 mg/day) for ≥12 weeks. Comparison groups could receive placebo or oral antidiabetic drugs (OAD) including metformin, sulphonylureas (SU), or dipeptidyl peptidase 4 inhibitors (DPP-4-i). Trials were identified through electronic databases and extensive manual searches. Primary outcomes were glycated haemoglobin A1c (HbA1c) levels, serious adverse events, death, severe hypoglycaemia, ketoacidosis and CVD. Secondary outcomes were fasting plasma glucose, body weight, blood pressure, heart rate, lipids, liver function tests, creatinine and adverse events including infections. The quality of the evidence was assessed using GRADE. RESULTS Meta-analysis of 34 RCTs with 9,154 patients showed that SGLT2-i reduced HbA1c compared with placebo (mean difference -0.69%, 95% confidence interval -0.75 to -0.62%). We downgraded the evidence to 'low quality' due to variability and evidence of publication bias (P = 0.015). Canagliflozin was associated with the largest reduction in HbA1c (-0.85%, -0.99% to -0.71%). There were no differences between SGLT2-i and placebo for serious adverse events. SGLT2-i increased the risk of urinary and genital tract infections and increased serum creatinine, and exerted beneficial effects on bodyweight, blood pressure, lipids and alanine aminotransferase (moderate to low quality evidence). Analysis of 12 RCTs found a beneficial effect of SGLT2-i on HbA1c compared with OAD (-0.20%, -0.28 to -0.13%; moderate quality evidence). CONCLUSION This review includes a large number of patients with type 2 diabetes and found that SGLT2-i reduces HbA1c with a notable increased risk in non-serious adverse events. The analyses may overestimate the intervention benefit due bias.
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Affiliation(s)
- Heidi Storgaard
- Centre for Diabetes Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Lise L. Gluud
- Gastrounit, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark
| | - Cathy Bennett
- Centre for Technology Enabled Health Research, Coventry University, Coventry, United Kingdom
| | - Magnus F. Grøndahl
- Centre for Diabetes Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Mikkel B. Christensen
- Centre for Diabetes Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Pharmacology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Filip K. Knop
- Centre for Diabetes Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Novo Nordisk Foundation Centre for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tina Vilsbøll
- Centre for Diabetes Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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263
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Dalama B, Mesa J. Nuevos hipoglucemiantes orales y riesgo cardiovascular. Cruzando la frontera metabólica. Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2016.07.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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264
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Abstract
SGLT2 inhibitors are glucose-lowering agents used to treat type 2 diabetes mellitus (T2DM). These agents target the kidney to promote urinary glucose excretion, resulting in improved blood glucose control. SGLT2-inhibitor therapy is also associated with weight loss and blood pressure (BP) lowering. Hypertension is a common comorbidity in patients with T2DM, and is associated with excess morbidity and mortality. This review summarizes data on the effect of SGLT2 inhibitors marketed in the US (namely canagliflozin, dapagliflozin, or empagliflozin) on BP in patients with T2DM. Boolean searches were conducted that included terms related to BP or hypertension with terms for SGLT2 inhibitors, canagliflozin, dapagliflozin, or empagliflozin using PubMed, Google, and Google Scholar. Data from numerous randomized controlled trials of SGLT2 inhibitors in patients with T2DM demonstrated clinically relevant reductions in both systolic and diastolic BP, assessed via seated office measurements and 24-hour ambulatory BP monitoring. Observed BP lowering was not associated with compensatory increases in heart rate. Circadian BP rhythm was also maintained. The mechanism of SGLT2 inhibitor-associated BP reduction is not fully understood, but is assumed to be related to osmotic diuresis and natriuresis. Other factors that may also contribute to BP reduction include SGLT2 inhibitor-associated decreases in body weight and reduced arterial stiffness. Local inhibition of the renin-angiotensin-aldosterone system secondary to increased delivery of sodium to the juxtaglomerular apparatus during SGLT2 inhibition has also been postulated. Although SGLT2 inhibitors are not indicated as BP-lowering agents, the modest decreases in systolic and diastolic BP observed with SGLT2 inhibitors may provide an extra clinical advantage for the majority of patients with T2DM, in addition to improving blood glucose control.
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265
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Madaan T, Akhtar M, Najmi AK. Sodium glucose CoTransporter 2 (SGLT2) inhibitors: Current status and future perspective. Eur J Pharm Sci 2016; 93:244-52. [DOI: 10.1016/j.ejps.2016.08.025] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/21/2016] [Accepted: 08/11/2016] [Indexed: 02/06/2023]
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Abstract
Inhibitors of sodium-glucose cotransporters type 2 (SGLT2) reduce hyperglycemia by increasing urinary glucose excretion. They have been evaluated in patients with type 2 diabetes treated with diet/exercise, metformin, dual oral therapy or insulin. Three agents are available in Europe and the USA (canagliflozin, dapagliflozin, empagliflozin) and others are commercialized in Japan or in clinical development. SGLT2 inhibitors reduce glycated hemoglobin, with a minimal risk of hypoglycemia. They exert favorable effects beyond glucose control with consistent body weight, blood pressure, and serum uric acid reductions. Empagliflozin showed remarkable reductions in cardiovascular/all-cause mortality and in hospitalization for heart failure in patients with previous cardiovascular disease. Positive renal outcomes were also shown with empagliflozin. Mostly reported adverse events are genital mycotic infections, while urinary tract infections and events linked to volume depletion are rather rare. Concern about a risk of ketoacidosis and bone fractures has been recently raised, which deserves caution and further evaluation.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
- Department of Medicine, CHU Sart Tilman (B35), B-4000, Liege 1, Belgium.
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267
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Dalama B, Mesa J. New Oral Hypoglycemic Agents and Cardiovascular Risk. Crossing the Metabolic Border. ACTA ACUST UNITED AC 2016; 69:1088-1097. [PMID: 27687335 DOI: 10.1016/j.rec.2016.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 07/05/2016] [Indexed: 12/19/2022]
Abstract
Sodium-glucose cotransporter 2 inhibitors are a novel pharmacological class of oral hypoglycemic agents that lower glucose levels by increasing renal glucose excretion in an insulin-independent manner. However, this seemingly simple mechanism has more complex indirect metabolic effects. The results of randomized clinical trials have shown that these inhibitors effectively lower blood glucose and glycated hemoglobin levels without increasing the risk of hypoglycemia and, at the same time, also reduce bodyweight and systolic blood pressure. In this review, we describe the mechanism of action, efficacy, and safety of currently marketed drugs, as well as other risk factors besides glucose that can potentially be modulated positively. Recent data on empagliflozin showing a significant cardiovascular benefit have compelled us to update knowledge of this new therapeutic class for the treatment of type 2 diabetes.
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Affiliation(s)
- Belén Dalama
- Servicio de Endocrinología y Nutrición, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
| | - Jordi Mesa
- Servicio de Endocrinología y Nutrición, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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268
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Marín-Peñalver JJ, Martín-Timón I, Sevillano-Collantes C, del Cañizo-Gómez FJ. Update on the treatment of type 2 diabetes mellitus. World J Diabetes 2016; 7:354-95. [PMID: 27660695 PMCID: PMC5027002 DOI: 10.4239/wjd.v7.i17.354] [Citation(s) in RCA: 334] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/02/2016] [Accepted: 07/20/2016] [Indexed: 02/05/2023] Open
Abstract
To achieve good metabolic control in diabetes and keep long term, a combination of changes in lifestyle and pharmacological treatment is necessary. Achieving near-normal glycated hemoglobin significantly, decreases risk of macrovascular and microvascular complications. At present there are different treatments, both oral and injectable, available for the treatment of type 2 diabetes mellitus (T2DM). Treatment algorithms designed to reduce the development or progression of the complications of diabetes emphasizes the need for good glycaemic control. The aim of this review is to perform an update on the benefits and limitations of different drugs, both current and future, for the treatment of T2DM. Initial intervention should focus on lifestyle changes. Moreover, changes in lifestyle have proven to be beneficial, but for many patients is a complication keep long term. Physicians should be familiar with the different types of existing drugs for the treatment of diabetes and select the most effective, safe and better tolerated by patients. Metformin remains the first choice of treatment for most patients. Other alternative or second-line treatment options should be individualized depending on the characteristics of each patient. This article reviews the treatments available for patients with T2DM, with an emphasis on agents introduced within the last decade.
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269
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Harris SB. The power of two: an update on fixed-dose combinations for type 2 diabetes. Expert Rev Clin Pharmacol 2016; 9:1453-1462. [DOI: 10.1080/17512433.2016.1221758] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Stewart B. Harris
- Department of Family Medicine, Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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270
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Sano M, Meguro S, Kawai T, Suzuki Y. Increased grip strength with sodium-glucose cotransporter 2. J Diabetes 2016; 8:736-7. [PMID: 27038414 DOI: 10.1111/1753-0407.12402] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 03/28/2016] [Indexed: 01/10/2023] Open
Affiliation(s)
- Motoaki Sano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shu Meguro
- Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Toshihide Kawai
- Department of Internal Medicine, Saiseikai Central Hospital, Tokyo, Japan
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271
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Carlson CJ, Santamarina ML. Update review of the safety of sodium-glucose cotransporter 2 inhibitors for the treatment of patients with type 2 diabetes mellitus. Expert Opin Drug Saf 2016; 15:1401-12. [PMID: 27449721 DOI: 10.1080/14740338.2016.1216100] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Curt J. Carlson
- Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL, USA
| | - Marile L. Santamarina
- Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, FL, USA
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272
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Zaccardi F, Webb DR, Htike ZZ, Youssef D, Khunti K, Davies MJ. Efficacy and safety of sodium-glucose co-transporter-2 inhibitors in type 2 diabetes mellitus: systematic review and network meta-analysis. Diabetes Obes Metab 2016; 18:783-94. [PMID: 27059700 DOI: 10.1111/dom.12670] [Citation(s) in RCA: 320] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 03/24/2016] [Accepted: 03/31/2016] [Indexed: 12/13/2022]
Abstract
AIM To assess the comparative efficacy and safety of sodium-glucose co-transporter-2 (SGLT2) inhibitors in adults with type 2 diabetes. METHODS We electronically searched randomized controlled trials (≥24 weeks) including canagliflozin, dapagliflozin or empagliflozin that were published up to 3 November 2015. Data were collected on cardiometabolic and safety outcomes and synthesized using network meta-analyses. RESULTS A total of 38 trials (23 997 participants) were included. Compared with placebo, all SGLT2 inhibitors reduced glycated haemoglobin (HbA1c), fasting plasma glucose (FPG), body weight and blood pressure, and slightly increased HDL cholesterol. Canagliflozin 300 mg reduced HbA1c, FPG and systolic blood pressure and increased LDL cholesterol to a greater extent compared with other inhibitors at any dose. At their highest doses, canagliflozin 300 mg reduced: HbA1c by 0.2% [95% confidence interval (CI) 0.1-0.3] versus both dapagliflozin 10 mg and empagliflozin 25 mg; FPG by 0.6 mmol/l (95% CI 0.3-0.9) and 0.5 mmol/l (95% CI 0.1-0.8) versus dapagliflozin and empagliflozin, respectively; and systolic blood pressure by 2 mmHg (95% CI 1.0-3.0) versus dapagliflozin; and increased LDL cholesterol by 0.13 mmol/l (95% CI 0.03-0.23) and 0.15 mmol/l (95% CI 0.06-0.23) versus dapagliflozin and empagliflozin, respectively. The highest doses of inhibitors had similar effects on body weight reduction. Canagliflozin 300 and 100 mg increased the risk of hypoglycaemia versus placebo, dapagliflozin 10 mg and empagliflozin 10 mg [odds ratios (ORs) 1.4-1.6]. Dapagliflozin 10 mg increased the risk of urinary tract infection versus placebo and empagliflozin 25 mg (ORs 1.4). All inhibitors similarly increased the risk of genital infection (ORs 4-6 versus placebo). CONCLUSIONS Although they increase the risk of genital infection, SGLT2 inhibitors are effective in improving cardiometabolic markers in type 2 diabetes, with canagliflozin 300 mg performing better in this respect than other inhibitors. Further studies will clarify whether these differences are likely to translate into differing long-term outcomes.
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Affiliation(s)
- F Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Center, Leicester Diabetes Centre, UHL NHS Trust, Leicester, UK
| | - D R Webb
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Center, Leicester Diabetes Centre, UHL NHS Trust, Leicester, UK
| | - Z Z Htike
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Center, Leicester Diabetes Centre, UHL NHS Trust, Leicester, UK
| | - D Youssef
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Center, Leicester Diabetes Centre, UHL NHS Trust, Leicester, UK
| | - K Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Center, Leicester Diabetes Centre, UHL NHS Trust, Leicester, UK
| | - M J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Center, Leicester Diabetes Centre, UHL NHS Trust, Leicester, UK
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273
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Monica Reddy RP, Inzucchi SE. SGLT2 inhibitors in the management of type 2 diabetes. Endocrine 2016; 53:364-72. [PMID: 27270407 DOI: 10.1007/s12020-016-0943-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 03/24/2016] [Indexed: 01/07/2023]
Abstract
The glucose-lowering pharmacopeia continues to grow for patients with type 2 diabetes. The latest drug category, the SGLT2 inhibitors reduce glycated hemoglobin concentrations by increasing urinary excretion of glucose. They are used mainly in combination with metformin and other antihyperglycemic agents, including insulin. Their glucose-lowering potency is modest. Advantages include lack of hypoglycemia as a side effect, and mild reduction in blood pressure and body weight. Side effects include increased urinary frequency, owing to their mild diuretic action, symptoms of hypovolemia, genitourinary infections. There are also recent reports of rare cases of diabetic ketoacidosis occurring in insulin-treated patients. Recently, a large cardiovascular outcome trial reported that a specific SGLT2 inhibitor, empagliflozin, led to a reduction in the primary endpoint of major cardiovascular events. This effect was mainly the result of a surprising 38 % reduction in cardiovascular death, and the drug was also associated with nearly as large a reduction in heart failure hospitalization. These findings were notable because most drugs used in type 2 diabetes have not been shown to improve cardiovascular outcomes. Accordingly, there is growing interest in empagliflozin and the entire SGLT2 inhibitor class as drugs that could potentially change the manner in which we approach the management of hyperglycemia in patients with type 2 diabetes.
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Affiliation(s)
| | - Silvio E Inzucchi
- Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT, USA.
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274
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Wilding JPH, Rajeev SP, DeFronzo RA. Positioning SGLT2 Inhibitors/Incretin-Based Therapies in the Treatment Algorithm. Diabetes Care 2016; 39 Suppl 2:S154-64. [PMID: 27440828 DOI: 10.2337/dcs15-3005] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are the most recent addition to the therapeutic options available for the treatment of type 2 diabetes and became available after the introduction of incretin-based therapies, dipeptidyl peptidase 4 inhibitors and glucagon-like peptide 1 receptor agonists (GLP-1 RAs). These agents have potential advantages with regard to their weight loss-promoting effect, low risk of hypoglycemia, reduction in blood pressure, and reduction in cardiovascular events in high-risk patients (with empagliflozin). Apart from these clinically important outcomes, they may also correct core defects present in type 2 diabetes (i.e., improvement in β-cell function and insulin sensitivity). They do, however, have some adverse effects, notably, nausea with GLP-1 RAs and genital tract infections and potential for volume depletion with SGLT2i. Whether incretin-based therapies are associated with an increased risk of pancreatitis is unclear. Most recently, diabetic ketoacidosis has been reported with SGLT2i. Therefore, a key clinical question in relation to guidelines is whether these clinical advantages, in the context of the adverse effect profile, outweigh the additional cost compared with older, more established therapies. This article reviews the therapeutic rationale for the use of these newer drugs for diabetes treatment, considers their place in current guidelines, and discusses how this may change as new data emerge about their long-term efficacy and safety from ongoing outcome trials.
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Affiliation(s)
- John P H Wilding
- Obesity and Endocrinology Clinical Research, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, U.K.
| | - Surya Panicker Rajeev
- Obesity and Endocrinology Clinical Research, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, U.K
| | - Ralph A DeFronzo
- Diabetes Division, The University of Texas Health Science Center at San Antonio, San Antonio, TX
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275
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Yamamoto C, Miyoshi H, Ono K, Sugawara H, Kameda R, Ichiyama M, Yamamoto K, Nomoto H, Nakamura A, Atsumi T. Ipragliflozin effectively reduced visceral fat in Japanese patients with type 2 diabetes under adequate diet therapy. Endocr J 2016; 63:589-96. [PMID: 27052123 DOI: 10.1507/endocrj.ej15-0749] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
To investigate if ipragliflozin, a novel sodium-glucose co-transporter 2 inhibitor, alters body composition and to identify variables associated with reductions in visceral adipose tissue in Japanese patients with type 2 diabetes mellitus. This prospective observational study enrolled Japanese participants with type 2 diabetes mellitus. Subjects were administered ipragliflozin (50 mg/day) once daily for 16 weeks. Body composition, visceral adipose tissue volume and plasma variables were measured at 0, 8, and 16-weeks. The subjects' lifestyle habits including diet and exercise were evaluated at baseline and 16 weeks. The primary endpoint was defined as the decrease of visceral adipose tissue mass. Twenty-four of 26 enrolled participants completed the study. The visceral adipose tissue decreased significantly (110 ± 33 to 101 ± 36 cm(2), p = 0.005) as well as other parameters for metabolic insufficiency including hemoglobin A1c. Seventy-one % of the total body weight reduction (-2.49 kg) was estimated by a decrease in fat mass (-1.77 kg), and the remaining reduction (22%) by water volume (-0.55 kg). A minor but significant reduction in the skeletal muscle index was also observed. Correlation analyses were performed to identify variables associated with changes in visceral adipose tissue and the only significant variable identified was diet therapy (Spearman's r = -0.416, p = 0.043). Ipragliflozin significantly decreased visceral adipose tissue, and improved parametres for metabolic dysfunction. Adequate diet therapy would be necessary to induce and enhance the therapeutic merit.
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Affiliation(s)
- Chiho Yamamoto
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo 060-8638, Japan
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276
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Atageldiyeva K, Fujita Y, Yanagimachi T, Mizumoto K, Takeda Y, Honjo J, Takiyama Y, Abiko A, Makino Y, Haneda M. Sodium-Glucose Cotransporter 2 Inhibitor and a Low Carbohydrate Diet Affect Gluconeogenesis and Glycogen Content Differently in the Kidney and the Liver of Non-Diabetic Mice. PLoS One 2016; 11:e0157672. [PMID: 27327650 PMCID: PMC4915669 DOI: 10.1371/journal.pone.0157672] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 06/02/2016] [Indexed: 01/01/2023] Open
Abstract
A low carbohydrate diet (LCHD) as well as sodium glucose cotransporter 2 inhibitors (SGLT2i) may reduce glucose utilization and improve metabolic disorders. However, it is not clear how different or similar the effects of LCHD and SGLT2i are on metabolic parameters such as insulin sensitivity, fat accumulation, and especially gluconeogenesis in the kidney and the liver. We conducted an 8-week study using non-diabetic mice, which were fed ad-libitum with LCHD or a normal carbohydrate diet (NCHD) and treated with/without the SGLT-2 inhibitor, ipragliflozin. We compared metabolic parameters, gene expression for transcripts related to glucose and fat metabolism, and glycogen content in the kidney and the liver among the groups. SGLT2i but not LCHD improved glucose excursion after an oral glucose load compared to NCHD, although all groups presented comparable non-fasted glycemia. Both the LCHD and SGLT2i treatments increased calorie-intake, whereas only the LCHD increased body weight compared to the NCHD, epididimal fat mass and developed insulin resistance. Gene expression of certain gluconeogenic enzymes was simultaneously upregulated in the kidney of SGLT2i treated group, as well as in the liver of the LCHD treated group. The SGLT2i treated groups showed markedly lower glycogen content in the liver, but induced glycogen accumulation in the kidney. We conclude that LCHD induces deleterious metabolic changes in the non-diabetic mice. Our results suggest that SGLT2i induced gluconeogenesis mainly in the kidney, whereas for LCHD it was predominantly in the liver.
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Affiliation(s)
- Kuralay Atageldiyeva
- Division of Metabolism an Biosystemic Science, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yukihiro Fujita
- Division of Metabolism an Biosystemic Science, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
- * E-mail:
| | - Tsuyoshi Yanagimachi
- Division of Metabolism an Biosystemic Science, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Katsutoshi Mizumoto
- Division of Metabolism an Biosystemic Science, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yasutaka Takeda
- Division of Metabolism an Biosystemic Science, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Jun Honjo
- Division of Metabolism an Biosystemic Science, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yumi Takiyama
- Division of Metabolism an Biosystemic Science, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Atsuko Abiko
- Division of Metabolism an Biosystemic Science, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yuichi Makino
- Division of Metabolism an Biosystemic Science, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Masakazu Haneda
- Division of Metabolism an Biosystemic Science, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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277
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Gurgle HE, White K, McAdam-Marx C. SGLT2 inhibitors or GLP-1 receptor agonists as second-line therapy in type 2 diabetes: patient selection and perspectives. Vasc Health Risk Manag 2016; 12:239-49. [PMID: 27350752 PMCID: PMC4902150 DOI: 10.2147/vhrm.s83088] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Controversy exists regarding the selection of second-line therapy for patients with type 2 diabetes mellitus (T2DM) who are unable to achieve glycemic control with metformin therapy alone. Newer pharmacologic treatments for T2DM include glucagon-like peptide-1 receptor agonists and sodium–glucose cotransporter 2 inhibitors. Both the classes of medication are efficacious, exhibit positive effects on weight, and are associated with minimal risk of hypoglycemia. The purpose of this review is to compare the clinical trial and real-world effectiveness data of glucagon-like peptide-1 receptor agonists versus sodium–glucose cotransporter 2 inhibitors related to A1c reduction, weight loss, cost-effectiveness, cardiovascular outcomes, and safety in patients with T2DM. This review summarizes comparative evidence for providers who are determining which of the two classes may be the most appropriate for a specific patient.
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Affiliation(s)
- Holly E Gurgle
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Karen White
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Carrie McAdam-Marx
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
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278
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Sodium-glucose cotransporter-2 inhibitors and blood pressure decrease: a valuable effect of a novel antidiabetic class? J Hypertens 2016; 33:2185-97. [PMID: 26372321 DOI: 10.1097/hjh.0000000000000719] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diabetes mellitus is a major issue of public health, affecting more than 300 million people worldwide. Inhibitors of the sodium-glucose cotransporter-2 (SGLT-2) in the renal proximal tubule are a novel class of agents for the treatment of type 2 diabetes mellitus. Inhibition of the SGLT-2 results in reduced glucose reabsorption and improvement in glycemic control. Alongside glucose excretion, SGLT-2 inhibitors also have mild natriuretic and diuretic effects, combining actions of a proximal tubule diuretic and an osmotic diuretic; these properties are expected to lead to small blood pressure (BP) reductions. Clinical studies with dapagliflozin, canagliflozin, empagliflozin, ipragliflozin, luseogliflozin, and tofogliflozin used either as monotherapy or add-on therapy and compared with placebo or active treatment have also examined the effect of these agents on BP as a secondary endpoint. Although with some differences between individual agents, all of the approved SGLT-2 inhibitors provided a mild but meaningful reduction in office SBP and DBP. Recent studies with the use of ambulatory blood pressure monitoring suggest that the magnitude of this BP reduction can be even greater. The aim of this review is to systematically summarize and present the studies reporting the effect of approved SGLT-2 inhibitors on BP.
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Heerspink HJL, Johnsson E, Gause-Nilsson I, Cain VA, Sjöström CD. Dapagliflozin reduces albuminuria in patients with diabetes and hypertension receiving renin-angiotensin blockers. Diabetes Obes Metab 2016; 18:590-7. [PMID: 26936519 PMCID: PMC4850750 DOI: 10.1111/dom.12654] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 01/23/2016] [Accepted: 02/27/2016] [Indexed: 01/10/2023]
Abstract
AIMS To characterize the effect of dapagliflozin on albuminuria and estimated glomerular filtration rate (eGFR) and to determine whether effects on albuminuria were mediated through changes in glycated haemoblogin (HbA1c), systolic blood pressure (SBP), body weight or eGFR. METHODS We conducted a post hoc analysis of data pooled from two phase III clinical trials in hypertensive patients with type 2 diabetes (T2DM) on stable angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy, randomly assigned to dapagliflozin 10 mg/day or matched placebo. This analysis included only patients with microalbuminuria or macroalbuminuria at baseline. RESULTS Patients were randomized to receive dapagliflozin 10 mg (n = 167) or placebo (n = 189). Dapagliflozin resulted in greater 12-week reductions in albuminuria compared with placebo: -33.2% [95% confidence interval (CI) -45.4, -18.2]. The reduction in albuminuria was also present after adjusting for age, sex and changes in HbA1c, SBP, body weight and eGFR: -23.5% (95% CI -37.6, -6.3). There was a decrease in eGFR with dapagliflozin versus placebo that was readily reversed 1 week after last dose. No serious renal-related adverse events were observed in any group. CONCLUSIONS Dapagliflozin was effective in lowering albuminuria in patients with T2DM and hypertension using renin-angiotensin system blockade therapy. Reductions in albuminuria were still present after adjusting for changes in HbA1c, SBP, body weight and eGFR. Dapagliflozin-induced improvements in glycaemic control and reductions in SBP, coupled with other potentially beneficial renal effects, may lead to a reduced long-term renal and cardiovascular risk.
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Affiliation(s)
- H J L Heerspink
- University of Groningen, University Medical Center, Groningen, The Netherlands
| | - E Johnsson
- AstraZeneca, Gothenburg, Mölndal, Sweden
| | | | - V A Cain
- AstraZeneca, Wilmington, DE, USA
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280
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Marx N, McGuire DK. Sodium-glucose cotransporter-2 inhibition for the reduction of cardiovascular events in high-risk patients with diabetes mellitus. Eur Heart J 2016; 37:3192-3200. [DOI: 10.1093/eurheartj/ehw110] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 02/19/2016] [Accepted: 02/29/2016] [Indexed: 12/15/2022] Open
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281
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Schwartz SS, Ahmed I. Sodium-glucose cotransporter 2 inhibitors: an evidence-based practice approach to their use in the natural history of type 2 diabetes. Curr Med Res Opin 2016; 32:907-19. [PMID: 26854518 DOI: 10.1185/03007995.2016.1151774] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective The sodium-glucose cotransporter 2 (SGLT-2) inhibitors are an important addition to available treatments for patients with type 2 diabetes (T2D) as an adjunct to modifications in diet and exercise. SGLT-2 inhibitors may be prescribed alone or as add-on treatment in patients receiving metformin, sulfonylureas, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, and/or insulin across the natural history of the disease. Inhibition of SGLT-2, which is responsible for approximately 90% of renal glucose reabsorption, increases urinary glucose excretion and lowers blood glucose concentrations. The objective of this review is to discuss the pathophysiology of diabetes and the contribution of the kidney to glucose homeostasis and to provide an evidence-based practice approach to clinical applications of SGLT-2 inhibitors in the treatment of T2D. Methods PubMed and Google Scholar databases were searched to identify literature published from 1990 through September 2015 examining the pathophysiology of T2D, the role of the kidney in regulating glucose concentrations, and clinical evidence for the efficacy and safety of SGLT-2 inhibitors in T2D. Results There is a need for early treatment in patients with T2D to minimize the risk of cardiovascular complications that increase morbidity and mortality. SGLT-2 inhibitors improve glycemic control, reduce body weight and blood pressure, and are associated with a low risk of hypoglycemia. Adverse events associated with SGLT-2 inhibitors include mild to moderate urinary tract and genital infections and mild dehydration potentially leading to orthostatic hypotension. Conclusions An evidence-based practice approach to examining the importance of early, proactive treatment of T2D using SGLT-2 inhibitors from initiation of pharmacotherapy to increasingly more complicated combination therapy regimens, including insulin, suggests that this treatment strategy maximizes benefits and minimizes potential side effects. The SGLT-2 inhibitors augment the arsenal of available antidiabetes agents, facilitating the ability of clinicians to design tailored treatment regimens that help patients achieve therapeutic goals.
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Affiliation(s)
| | - Intekhab Ahmed
- b Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine , Thomas Jefferson University , Philadelphia , PA , USA
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282
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Wu JHY, Foote C, Blomster J, Toyama T, Perkovic V, Sundström J, Neal B. Effects of sodium-glucose cotransporter-2 inhibitors on cardiovascular events, death, and major safety outcomes in adults with type 2 diabetes: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2016; 4:411-9. [PMID: 27009625 DOI: 10.1016/s2213-8587(16)00052-8] [Citation(s) in RCA: 340] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/10/2016] [Accepted: 02/10/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND In patients with type 2 diabetes, sodium-glucose cotransporter-2 (SGLT2) inhibitors are known to reduce glucose concentrations, blood pressure, and weight, but to increase LDL cholesterol and the incidence of urogenital infections. Protection against cardiovascular events has also been reported, as have possible increased risks of adverse outcomes such as ketoacidosis and bone fracture. We aimed to establish the effects of SGLT2 inhibitors on cardiovascular events, death, and safety outcomes in adults with type 2 diabetes, both overall and separately for individual drugs. METHODS In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, and websites of US, European, and Japanese regulatory authorities from Jan 1, 1950, to Sept 30, 2015, for data from prospective randomised controlled trials assessing the effects of SGLT2 treatment compared with controls. We excluded duplicate reports, trials of compound drugs, trials that lasted 7 days or fewer, trials that did not report on outcomes of interest, and articles that presented pooled trial data for which the individual trials could not be identified. We extracted data in duplicate using a standardised approach. The primary outcome was major adverse cardiovascular events. Secondary outcomes were cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, admission to hospital for unstable angina, heart failure, and all-cause mortality. We estimated summary relative risks with fixed-effects meta-analysis, with the I(2) statistic used to estimate heterogeneity of results beyond chance. FINDINGS The analyses included data from six regulatory submissions (37 525 participants) and 57 published trials (33 385 participants), which provided data for seven different SGLT2 inhibitors. SGLT2 inhibitors protected against the risk of major adverse cardiovascular events (relative risk 0·84 [95% CI 0·75-0·95]; p=0·006), cardiovascular death (0·63 [0·51-0·77]; p<0·0001), heart failure (0·65 [0·50-0·85]; p=0·002), and death from any cause (0·71 [0·61-0·83]; p<0·0001). No clear effect was apparent for non-fatal myocardial infarction (0·88 [0·72-1·07]; p=0·18) or angina (0·95 [0·73-1·23]; p=0·70), but we noted an adverse effect for non-fatal stroke (1·30 [1·00-1·68]; p=0·049). We noted no clear evidence that the individual drugs had different effects on cardiovascular outcomes or death (all I(2)<43%). Safety analyses showed consistent increased risks of genital infections (regulatory submissions 4·75 [4·00-5·63]; scientific reports 2·88 [2·48-3·34]), but findings for some safety outcomes varied depending on whether anlayses were based on data extracted from regulatory submissions or trials reported in the scientific literature. INTERPRETATION These data suggest net protection of SGLT2 inhibitors against cardiovascular outcomes and death. The efficacy results were driven by findings for empagliflozin (the only SGLT2 inhibitor for which data from a dedicated long-term cardiovascular safety trial have been reported), although results for the other drugs in the class were not clearly different. Adverse events were more difficult to quantify than was efficacy, with the effects of individual drugs in the class seeming to differ for some safety outcomes. Results from ongoing studies will be crucial to substantiate these findings across the drug class, but the available data provide a strong rationale to expect benefit from use of SGLT2 inhibitors in patients with type 2 diabetes at high risk of cardiovascular events. FUNDING National Health and Medical Research Council of Australia.
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Affiliation(s)
- Jason H Y Wu
- The George Institute for Global Health, University of Sydney, Camperdown, Sydney, NSW, Australia
| | - Celine Foote
- The George Institute for Global Health, University of Sydney, Camperdown, Sydney, NSW, Australia; Concord Repatriation General Hospital, Concord, Sydney, NSW, Australia
| | - Juuso Blomster
- The George Institute for Global Health, University of Sydney, Camperdown, Sydney, NSW, Australia; University of Turku, Turku, Finland; Sahlgrenska Academy at University of Gothenberg, Gothenberg, Sweden
| | - Tadashi Toyama
- The George Institute for Global Health, University of Sydney, Camperdown, Sydney, NSW, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, University of Sydney, Camperdown, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Camperdown, Sydney, NSW, Australia
| | - Johan Sundström
- The George Institute for Global Health, University of Sydney, Camperdown, Sydney, NSW, Australia; Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala, Sweden
| | - Bruce Neal
- The George Institute for Global Health, University of Sydney, Camperdown, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Camperdown, Sydney, NSW, Australia; Imperial College London, London, UK.
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283
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de Wit HM, Te Groen M, Rovers MM, Tack CJ. The placebo response of injectable GLP-1 receptor agonists vs. oral DPP-4 inhibitors and SGLT-2 inhibitors: a systematic review and meta-analysis. Br J Clin Pharmacol 2016; 82:301-14. [PMID: 26935973 DOI: 10.1111/bcp.12925] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 02/26/2016] [Accepted: 02/29/2016] [Indexed: 02/06/2023] Open
Abstract
AIMS The size of the placebo response in type 2 diabetes (T2DM) treatment and its relation to the route of drug administration have not been systematically reviewed. We aimed to determine weight loss, change in HbA1c and incidence of adverse events after treatment with injectable placebo GLP-1 receptor agonist (GLP-1ra), compared with oral placebo DPP-4 inhibitor (DPP-4i) and placebo SGLT-2 inhibitor (SGLT-2i). METHODS PubMed, EMBASE and Central were searched up to September 2014 for randomized placebo controlled trials investigating GLP-1ra, DPP-4i or SGLT2-i. Data on placebo groups were extracted and pooled using a generic inverse variance random effects model. RESULTS Sixty-seven trials were included, involving 2522, 5290 and 2028 patients randomized to placebo GLP-1ra, placebo DPP-4i and placebo SGLT-2i, respectively. Body weight decreased by -0.67 kg (95% CI -1.03, -0.31) after treatment with placebo GLP-1ra (-0.76 kg [95% CI -1.10, -0.43] with placebo short acting GLP-1ra and -0.32 kg [95% CI -1.75, 1.10] with placebo long acting GLP-1ra) and by -0.31 kg (95% CI -0.64, 0.01) with placebo DPP-4i (P = 0.06 for difference with placebo short acting GLP-1ra). Placebo SGLT-2i resulted in an intermediate -0.48 kg (95% CI -0.81, -0.15) weight loss. Weight loss with placebo showed a strong correlation with the active comparator drug (r(2) = 0.40-0.78). HbA1c changed little with placebo treatment (-0.23%, 0.10% and -0.13% for placebo GLP-1ra, DPP-4i and SGLT-2i). Adverse events occurred frequently with placebo, were often similar to the active comparator drug and led to drop-out in 2.0-2.7% of cases. CONCLUSIONS The response to placebo treatment was related to its active comparator, with injectable placebo GLP-1ra showing a relevant response on weight, whereas oral placebo DPP4i showed no significant response. These findings may suggest that subjective expectations influence T2DM treatment efficacy, which can possibly be employed therapeutically.
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Affiliation(s)
- Helena M de Wit
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Maarten Te Groen
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Maroeska M Rovers
- Departments of Operating Rooms and Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Cees J Tack
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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284
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Munir KM, Davis SN. Differential pharmacology and clinical utility of empagliflozin in type 2 diabetes. Clin Pharmacol 2016; 8:19-34. [PMID: 27186083 PMCID: PMC4847607 DOI: 10.2147/cpaa.s77754] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
With rates of obesity and diabetes rising across the world, effective therapies to treat hyperglycemia and its associated comorbidities continue to be in demand. Empagliflozin is a highly selective sodium glucose transporter-2 inhibitor that improves serum glucose levels by inducing glucosuria. Taken orally, it is rapidly absorbed with linear pharmacokinetics consistent in Asian and Caucasian populations. Empagliflozin treatment demonstrates consistent reductions in hemoglobin A1c, fasting plasma glucose, body weight, and blood pressure in individuals with type 2 diabetes. Improvements in glycemic control and metabolic end points are evident with empagliflozin monotherapy, as add-on to oral hypoglycemics or add-on to insulin. The nonglycemic effects of empagliflozin with consistent improvements in blood pressure, body weight, and waist circumference provide additional rationale for use in patients with type 2 diabetes. Moreover, treatment with empagliflozin has recently shown significant reductions in both microvascular and macrovascular complications of diabetes.
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Affiliation(s)
- Kashif M Munir
- Division of Endocrinology, Diabetes, and Nutrition, Center for Diabetes and Endocrinology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stephen N Davis
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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285
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de Leeuw AE, de Boer RA. Sodium-glucose cotransporter 2 inhibition: cardioprotection by treating diabetes-a translational viewpoint explaining its potential salutary effects. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2016; 2:244-55. [PMID: 27533948 DOI: 10.1093/ehjcvp/pvw009] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 04/12/2016] [Indexed: 12/21/2022]
Abstract
Diabetes is a growing epidemic worldwide characterized by an elevated concentration of blood glucose, associated with a high incidence of cardiovascular disease and mortality. Although in general reduction of hyperglycaemia is considered a therapeutic goal, hypoglycaemic therapies do not necessarily reduce cardiovascular mortality and may even aggravate cardiovascular risk factors, such as body weight. A new class of antidiabetic drugs acts by inhibition of the sodium-glucose cotransporter 2 (SGLT2), which (partially) prevents reabsorption of glucose from the renal filtrate. The induction of glucose excretion via the urine (glycosuria) was turned into an effective strategy to reduce blood glucose. Ancillary advantages are the caloric and volumetric loss and thereby the reduction of body weight and blood pressure. Additionally, SGLT2 inhibition has been suggested to exert direct cardioprotective effects by the reduction of cardiac fibrosis, inflammation, and oxidative stress. This article summarizes the functional consequences of SGLT2 inhibition on the diabetic and hyperglycaemic organism. We especially focused on the effects on the kidney and the cardiovascular system as described in experimental studies. The interesting observations in experimental studies may extend to clinical medicine, as a recent trial reported a decrease in heart failure outcomes in patients at high cardiovascular risk. In conclusion, SGLT2 inhibition represents a novel treatment, which might be a promising target not only to (further) reduce blood glucose but also to target other cardiovascular risk factors. More research and long-term follow-ups will reveal the specific influence of SGLT2 inhibition on the circulatory system and cardiovascular outcomes.
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Affiliation(s)
- Anne E de Leeuw
- Department of Cardiology, University of Groningen, University Medical Center Groningen (UMCG), AB43, Antonius Deusinglaan 1, Hanzeplein 1, 9713GZ Groningen, The Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, University of Groningen, University Medical Center Groningen (UMCG), AB43, Antonius Deusinglaan 1, Hanzeplein 1, 9713GZ Groningen, The Netherlands
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286
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Arakaki RF. Sodium-glucose cotransporter-2 inhibitors and genital and urinary tract infections in type 2 diabetes. Postgrad Med 2016; 128:409-17. [DOI: 10.1080/00325481.2016.1167570] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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287
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Steinberg HO. Sodium-glucose cotransporter 2 inhibitors and cardiovascular outcomes. Postgrad Med 2016; 128:398-408. [PMID: 26999348 DOI: 10.1080/00325481.2016.1168687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Type 2 diabetes mellitus (T2DM) is associated with an elevated risk of cardiovascular (CV) morbidity and mortality. Furthermore, many patients with T2DM have comorbidities that are risk factors for CV disease. While intensive glucose control reduces the risk of diabetic microvascular complications, its relationship to CV outcomes remains unclear. Consequently, the management of CV risk factors in patients with T2DM is complex, and factors other than blood glucose must be considered. Sodium-glucose cotransporter 2 (SGLT2) inhibitors, a class of oral glucose-lowering agents, are associated with reductions in blood pressure and body weight, in addition to decreasing hyperglycemia, and therefore have the potential to reduce CV risk in patients with T2DM. The clinical trial results of SGLT2 inhibitors regarding CV safety and outcomes are discussed, including data from the recently published EMPA-REG OUTCOME study. This trial was the first dedicated CV outcomes study to demonstrate that a glucose-lowering agent lowered CV mortality and all-cause mortality, and reduced hospitalization for heart failure in patients with T2DM at high risk of CV events.
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Affiliation(s)
- Helmut O Steinberg
- a Medicine-Endocrinology, Division of Endocrinology, Diabetes and Metabolism Faculty , University of Tennessee Health Science Center , Memphis , TN , USA
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288
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Schwartz SS, Katz A. Sodium-glucose cotransporter-2 inhibitor combination therapy to optimize glycemic control and tolerability in patients with type 2 diabetes: focus on dapagliflozin-metformin. Diabetes Metab Syndr Obes 2016; 9:71-82. [PMID: 27042132 PMCID: PMC4801192 DOI: 10.2147/dmso.s65588] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
In type 2 diabetes (T2D), early combination therapy using agents that target a number of the underlying pathophysiologic defects contributing to hyperglycemia may improve patient outcomes. For many patients, the combination of metformin with a sodium-glucose cotransporter-2 (SGLT-2) inhibitor may be a good option because these agents have complementary mechanisms of action, neutral-to-positive effects on body weight, and a low risk of hypoglycemia. This review focuses on the combination of metformin with dapagliflozin, a member of the SGLT-2 inhibitor class of antidiabetes agents. In clinical trials, the combination of dapagliflozin with metformin produced significant and sustained reductions in glycated hemoglobin and body weight in a broad range of adult patients with T2D, including those initiating pharmacotherapy and those with more advanced disease. These reductions were accompanied by modest decreases in blood pressure. Dapagliflozin as add-on therapy to metformin was well tolerated and associated with low rates of hypoglycemia. Genital infections and, in some studies, urinary tract infections were more frequent with dapagliflozin than with placebo. Early combination therapy with dapagliflozin and metformin may be a safe and appropriate treatment option that enables patients with T2D to achieve individualized glycemic goals as either initial combination therapy in treatment-naïve patients or as dapagliflozin add-on in patients inadequately controlled with metformin therapy.
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Affiliation(s)
- Stanley S Schwartz
- University of Pennsylvania, Philadelphia, PA, USA
- Main Line Health System, Ardmore, PA, USA
| | - Arie Katz
- AstraZeneca, Fort Washington, PA, USA
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289
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Obata A, Kubota N, Kubota T, Iwamoto M, Sato H, Sakurai Y, Takamoto I, Katsuyama H, Suzuki Y, Fukazawa M, Ikeda S, Iwayama K, Tokuyama K, Ueki K, Kadowaki T. Tofogliflozin Improves Insulin Resistance in Skeletal Muscle and Accelerates Lipolysis in Adipose Tissue in Male Mice. Endocrinology 2016; 157:1029-42. [PMID: 26713783 DOI: 10.1210/en.2015-1588] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Sodium glucose cotransporter 2 inhibitors have attracted attention as they exert antidiabetic and antiobesity effects. In this study, we investigated the effects of tofogliflozin on glucose homeostasis and its metabolic consequences and clarified the underlying molecular mechanisms. C57BL/6 mice were fed normal chow containing tofogliflozin (0.005%) for 20 weeks or a high-fat diet containing tofogliflozin (0.005%) for 8 weeks ad libitum. In addition, the animals were pair-fed in relation to controls to exclude the influence of increased food intake. Tofogliflozin reduced the body weight gain, mainly because of fat mass reduction associated with a diminished adipocyte size. Glucose tolerance and insulin sensitivity were ameliorated. The serum levels of nonesterified fatty acid and ketone bodies were increased and the respiratory quotient was decreased in the tofogliflozin-treated mice, suggesting the acceleration of lipolysis in the white adipose tissue and hepatic β-oxidation. In fact, the phosphorylation of hormone-sensitive lipase and the adipose triglyceride lipase protein levels in the white adipose tissue as well as the gene expressions related to β-oxidation, such as Cpt1α in the liver, were significantly increased. The hepatic triglyceride contents and the expression levels of lipogenic genes were decreased. Pair-fed mice exhibited almost the same results as mice fed an high-fat diet ad libitum. Moreover, a hyperinsulinemic-euglycemic clamp revealed that tofogliflozin improved insulin resistance by increasing glucose uptake, especially in the skeletal muscle, in pair-fed mice. Taken together, these results suggest tofogliflozin ameliorates insulin resistance and obesity by increasing glucose uptake in skeletal muscle and lipolysis in adipose tissue.
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Affiliation(s)
- Atsushi Obata
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Naoto Kubota
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Tetsuya Kubota
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Masahiko Iwamoto
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Hiroyuki Sato
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Yoshitaka Sakurai
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Iseki Takamoto
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Hisayuki Katsuyama
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Yoshiyuki Suzuki
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Masanori Fukazawa
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Sachiya Ikeda
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Kaito Iwayama
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Kumpei Tokuyama
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Kohjiro Ueki
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
| | - Takashi Kadowaki
- Department of Diabetes and Metabolic Diseases (A.O., N.K., T.Ku., M.I., H.S., Y.Sa., I.T., H.K., K.U., T.Ka.), Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo 113-8655, Japan; Translational Systems Biology and Medicine Initiative (N.K., T.Ka.), The University of Tokyo, Tokyo 113-8655, Japan; Clinical Nutrition Program (N.K., T.Ku.), National Institute of Health and Nutrition, National Institutes of Biomedical Innovation, Health and Nutrition, Osaka 567-0085, Japan; Laboratory for Metabolic Homeostasis (N.K., T.Ku.), Research Center of Allergy and Immunology, RIKEN Center for Integrative Medical Sciences, Kanagawa 230-0045, Japan; Division of Cardiovascular Medicine (T.Ku.), Toho University, Ohashi Hospital, Tokyo 153-8515, Japan; Research Division (Y.Su., M.F., S.I.), Chugai Pharmaceutical Co, Ltd, Gotemba, Shizuoka 412-8513, Japan; and Graduate School of Comprehensive Human Science (K.I., K.T.), University of Tsukuba, Tsukuba 305-8577, Japan
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Neeland IJ, McGuire DK, Chilton R, Crowe S, Lund SS, Woerle HJ, Broedl UC, Johansen OE. Empagliflozin reduces body weight and indices of adipose distribution in patients with type 2 diabetes mellitus. Diab Vasc Dis Res 2016; 13:119-26. [PMID: 26873905 PMCID: PMC4768401 DOI: 10.1177/1479164115616901] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AIMS To determine the effects of empagliflozin on adiposity indices among patients with type 2 diabetes mellitus. METHODS Changes in weight, waist circumference, estimated total body fat, index of central obesity and visceral adiposity index were assessed using analysis of covariance and testing of treatment by strata for age, sex and baseline waist circumference in patients with type 2 diabetes mellitus randomized to blinded treatment with empagliflozin versus placebo in clinical trials of 12 weeks (cohort 1) or 24 weeks (cohort 2) duration. RESULTS This study comprised 3300 patients (cohort 1, N = 823; cohort 2, N = 2477). Empagliflozin reduced weight, waist circumference and adiposity indices versus placebo in both cohorts. Adjusted mean (95% confidence interval) change from baseline in empagliflozin versus placebo was -1.7 kg (-2.1 to -1.4 kg) and -1.9 kg (-2.1 to -1.7 kg) for body weight (p < 0.001); -1.3 cm (-1.8 to -0.7 cm) and -1.3 cm (-1.7 to -1.0 cm) for waist circumference (p < 0.001); -0.2% (-0.7% to 0.3%; p = 0.45) and -0.3% (-0.7% to 0.0%; p = 0.08) for estimated total body fat; -0.007 (-0.011 to -0.004) and -0.008 (-0.010 to -0.006) for index of central obesity (p < 0.001); and -0.3 (-0.5 to 0.0; p = 0.07) and -0.4 (-0.7 to -0.1; p = 0.003) for visceral adiposity index in cohorts 1 and 2, respectively. Adipose reductions were seen across most age, sex and waist circumference subgroups. CONCLUSION Empagliflozin significantly reduced weight and adiposity indices with the potential to improve cardiometabolic risk among patients with type 2 diabetes mellitus.
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Affiliation(s)
- Ian J Neeland
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Chilton
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Susanne Crowe
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Søren S Lund
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Hans J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
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291
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Sonesson C, Johansson PA, Johnsson E, Gause-Nilsson I. Cardiovascular effects of dapagliflozin in patients with type 2 diabetes and different risk categories: a meta-analysis. Cardiovasc Diabetol 2016; 15:37. [PMID: 26895767 PMCID: PMC4761166 DOI: 10.1186/s12933-016-0356-y] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 02/10/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND A pre-specified meta-analysis of cardiovascular (CV) events from 21 phase 2b/3 dapagliflozin clinical trials was undertaken to characterise the CV profile of dapagliflozin. This showed no increase in CV risk with dapagliflozin compared with control (placebo or comparator treatment) with or without background glucose-lowering therapies. The analysis reported here aimed to characterise the CV profile of dapagliflozin in subgroups of patients in these 21 studies grouped by degree of CV risk, based on both baseline and in-study risk factors (including hypoglycaemic events), with a focus on major adverse CV events (MACE). METHODS Patients with type 2 diabetes, both overall and with different levels of CV risk, including CV disease (CVD) history, age and other CV risk factors, were analysed. A further analysis compared CV risk in patients who experienced a hypoglycaemic event prior to MACE and those who did not. Analyses were based on time to first event using a Cox proportional hazards model stratified by study comparing dapagliflozin versus control. RESULTS In total, 9339 patients were included in this meta-analysis; 5936 patients received dapagliflozin 2.5-10 mg (6668 patient-years) and 3403 received control (3882 patient-years). Dapagliflozin is not associated with increased CV risk and results further suggest the potential for a beneficial effect both in the overall population [Hazard Ratio (HR) 0.77; 95 % CI (0.54, 1.10) for MACE] and in those with a history of CVD [HR 0.80 (0.53, 1.22)]. These findings were consistent in patients with varying degrees of CV risk, including age, number and type of CVD events in medical history and number of CV risk factors present. Furthermore, there was no increased risk of MACE in patients who experienced a hypoglycaemic event compared with those who did not. CONCLUSIONS There was no suggestion of increased risk for MACE with dapagliflozin compared with control in any of the populations investigated. In addition, the results suggest the potential for a beneficial CV effect which is consistent with the multifactorial benefits on CV risk factors associated with sodium-glucose cotransporter-2 (SGLT2) inhibitors.
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Affiliation(s)
| | - Peter A Johansson
- AstraZeneca Gothenburg, Pepparedsleden 1, SE-431 83, Mölndal, Sweden.
| | - Eva Johnsson
- AstraZeneca Gothenburg, Pepparedsleden 1, SE-431 83, Mölndal, Sweden.
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292
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Rajeev SP, Cuthbertson DJ, Wilding JPH. Energy balance and metabolic changes with sodium-glucose co-transporter 2 inhibition. Diabetes Obes Metab 2016; 18:125-34. [PMID: 26403227 DOI: 10.1111/dom.12578] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 08/26/2015] [Accepted: 09/18/2015] [Indexed: 12/25/2022]
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors are the latest addition to the class of oral glucose-lowering drugs. They have been rapidly adopted into clinical practice because of therapeutic advantages, including weight loss and reduction in blood pressure, in addition to glycaemic benefits and a low intrinsic risk of hypoglycaemia. Although there are extensive data on the clinical effects of SGLT2 inhibition, the metabolic effects of inhibiting renal glucose reabsorption have not been fully described. Recent studies have identified compensatory metabolic effects, such as an increase in endogenous glucose production, and have also shown an increase in glucagon secretion during SGLT2 inhibition. In addition, there is a discrepancy between the expected and observed weight loss found in clinical studies on SGLT2 inhibitors, probably as a result of changes in energy balance with this treatment approach. SGLT2 inhibition is likely to have intriguing effects on whole body metabolism which have not been fully elucidated, and which, if explained, might help optimize the use of this new class of medicines.
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Affiliation(s)
- S P Rajeev
- Obesity and Endocrinology Research Group, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - D J Cuthbertson
- Obesity and Endocrinology Research Group, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - J P H Wilding
- Obesity and Endocrinology Research Group, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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294
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Shanbhogue VV, Mitchell DM, Rosen CJ, Bouxsein ML. Type 2 diabetes and the skeleton: new insights into sweet bones. Lancet Diabetes Endocrinol 2016; 4:159-73. [PMID: 26365605 DOI: 10.1016/s2213-8587(15)00283-1] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/16/2015] [Accepted: 07/20/2015] [Indexed: 12/15/2022]
Abstract
Substantial evidence shows that skeletal fragility should be considered among the complications associated with type 2 diabetes. Individuals with type 2 diabetes have increased fracture risk, despite normal bone mineral density (BMD) and high BMI-factors that are generally protective against fractures. The mechanisms underlying skeletal fragility in diabetes are not completely understood, but are multifactorial and likely include effects of obesity, hyperglycaemia, oxidative stress, and accumulation of advanced glycation end products, leading to altered bone metabolism, structure, and strength. Clinicians should be aware that BMD measurements underestimate fracture risk in people with type 2 diabetes, and that new treatments for diabetes, with neutral or positive effects on skeletal health, might play a part in the management of diabetes in those at high risk of fracture. Data for the optimum management of osteoporosis in patients with type 2 diabetes are scarce, but in the absence of evidence to the contrary, physicians should follow guidelines established for postmenopausal osteoporosis.
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Affiliation(s)
- Vikram V Shanbhogue
- Department of Endocrinology, Odense University Hospital, and Institute of Clinical Research, University of Southern Denmark, Odense Denmark
| | - Deborah M Mitchell
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Clifford J Rosen
- Center for Clinical and Translational Research, Maine Medical Center Research Institute, Scarborough, ME, USA
| | - Mary L Bouxsein
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
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295
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Scheerer MF, Rist R, Proske O, Meng A, Kostev K. Changes in HbA1c, body weight, and systolic blood pressure in type 2 diabetes patients initiating dapagliflozin therapy: a primary care database study. Diabetes Metab Syndr Obes 2016; 9:337-345. [PMID: 27822077 PMCID: PMC5096728 DOI: 10.2147/dmso.s116243] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
AIMS To investigate changes in glycated hemoglobin (HbA1c), body weight (BW), and systolic blood pressure (SBP) in type 2 diabetes (T2D) primary care patients initiating dapagliflozin treatment. METHODS T2D patients who started dapagliflozin in 985 general and 32 diabetologist practices (Disease Analyzer, Germany: December 2012-October 2014) were analyzed (3- and 6-month follow-up). Multivariate linear regression analyses were used to identify clinical characteristics and comorbidity associated with changes in HbA1c, BW, and SBP. RESULTS The study included 1,169 T2D patients (age: 62.5 years; men: 59.3%; diabetologist care: 23%) with newly initiated dapagliflozin therapy. At the 3-month stage, dapagliflozin significantly reduced HbA1c (-0.8%±1.4%) compared to the baseline (8.5%±1.5%) (P<0.001). Changes were maintained after 6 months (-0.8%±1.5%) (P<0.001). Patients with high baseline HbA1c values (>9%) showed greater reductions in HbA1c than the overall sample (3 months -1.8%, 6 months -1.8%; both P<0.05). BW and SBP also showed statistically significant reductions with dapagliflozin over 3 and 6 months (-2.2 kg, P<0.001; -2.2 mmHg, P=0.003 and -2.5 kg, P<0.001; -2.3 mmHg, P=0.011, respectively). After 3 months, 53% of patients achieved a reduction in both HbA1c and BW; the same holds true for 45% of patients at the 6-month mark. Similar results were observed both in general and diabetologist practices. In multivariate analyses, baseline HbA1c (parameter estimate: -0.6479) and diabetologist care (-0.2553) were independent predictors of HbA1c change (6 months) (all P<0.05). CONCLUSION T2D patients treated with dapagliflozin therapy achieved statistically significant reductions in HbA1c, BW, and SBP in a real-world primary and diabetologist care setting. The changes were comparable to the results of the dapagliflozin clinical trial program.
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Affiliation(s)
| | - Roland Rist
- Medical Department, AstraZeneca GmbH, Wedel, Germany
| | - Orm Proske
- Medical Department, AstraZeneca GmbH, Wedel, Germany
| | - Annika Meng
- IMS Health GmbH & Co. OHG, Frankfurt am Main, Germany
| | - Karel Kostev
- IMS Health GmbH & Co. OHG, Frankfurt am Main, Germany
- Correspondence: Karel Kostev, Epidemiology & Evidence-Based Medicine, Real-World Evidence Solutions, IMS Health GmbH & Co. OHG, Darmstädter Landstraße 108, 60598 Frankfurt am Main, Germany, Tel +49 69 6604 4878, Email
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296
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Hirose S, Nakajima S, Iwahashi Y, Seo A, Takahashi T, Tamori Y. Impact of the 8-week Administration of Tofogliflozin for Glycemic Control and Body Composition in Japanese Patients with Type 2 Diabetes Mellitus. Intern Med 2016; 55:3239-3245. [PMID: 27853064 PMCID: PMC5173489 DOI: 10.2169/internalmedicine.55.6367] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective The adverse effects of selective sodium-glucose co-transporter 2 (SGLT2) inhibitors generally appear within about two or three months after treatment initiation in Japan. Therefore, we investigated the impact of tofogliflozin, a class of SGLT2 inhibitors, on glycemic control and body composition during this period in Japanese patients with type 2 diabetes mellitus. Methods This single-arm open-label study enrolled 20 patients. Patients received tofogliflozin 20 mg once daily for 8 weeks. At week 8, changes from baseline in body weight, serum metabolic markers, and body composition were evaluated. Results A total of 17 patients completed the 8-week administration of tofogliflodin. No serious adverse events were noted. Hemoglobin A1c (HbA1c) decreased significantly, from 7.8% to 7.3% with 8-week administration of tofogliflozin. Both the body weight and body mass index (BMI) also decreased. In addition, a decreased renal function of the boundary zone and hemoconcentration were detected. As for body composition, the free fat mass, total body water, extracellular water and intracellular water were all decreased significantly. Interestingly, the amount of fat mass did not change. The degree of improvement in HbA1c was correlated with the baseline fat mass and BMI. Conclusion An eight-week administration of tofogliflozin improved glycemic control and reduced the body weight and free fat mass in type 2 diabetic patients without affecting the fat mass. In this period, the hematocrit level and renal function should be monitored to guard against hemoconcentration and renal impairment, respectively.
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Affiliation(s)
- Sachie Hirose
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Chibune General Hospital, Japan
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Abstract
PURPOSE OF REVIEW The sodium glucose cotransporter 2 (SGLT2) reabsorbs most of the glucose filtered by the kidneys. SGLT2 inhibitors reduce glucose reabsorption, thereby lowering blood glucose levels, and have been approved as new antihyperglycemic drugs. Although the therapeutic strategy is very promising, many questions remain. RECENT FINDINGS Using validated antibodies, SGLT2 expression was localized to the brush border of the early proximal tubule in the human kidney and was found upregulated in genetic murine models of type 1 and 2 diabetes. SGLT2 may functionally interact with the Na/H exchanger NHE3 in the proximal tubule. SGLT1-mediated reabsorption explains the fractional renal glucose reabsorption of 40-50% during SGLT2 inhibition. SGLT2 is expressed on pancreatic alfa cells where its inhibition induces glucagon secretion. SGLT2 inhibition lowers glomerular filtration rate in hyperfiltering diabetic patients consistent with the tubular hypothesis of diabetic hyperfiltration. New data indicate a potential of SGLT2 inhibition for renal medullary hypoxia and ketoacidosis, but also for blood glucose effect-dependent and independent nephroprotective actions, renal gluconeogenesis inhibition, reduction in cardiovascular mortality, and cancer therapy. SUMMARY The findings expand and refine our understanding of SGLT2 and its inhibition, have relevance for clinical practice, and will help interpret ongoing clinical trials on the long-term safety and cardiovascular effects of SGLT2 inhibitors.
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Affiliation(s)
- Aleksandra Novikov
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA
- Veterans Affairs San Diego Healthcare System, San Diego, CA
| | - Volker Vallon
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA
- Veterans Affairs San Diego Healthcare System, San Diego, CA
- Department of Pharmacology, University of California San Diego, La Jolla, CA
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298
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Roden M, Merker L, Christiansen AV, Roux F, Salsali A, Kim G, Stella P, Woerle HJ, Broedl UC. Safety, tolerability and effects on cardiometabolic risk factors of empagliflozin monotherapy in drug-naïve patients with type 2 diabetes: a double-blind extension of a Phase III randomized controlled trial. Cardiovasc Diabetol 2015; 14:154. [PMID: 26701110 PMCID: PMC4690334 DOI: 10.1186/s12933-015-0314-0] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 12/08/2015] [Indexed: 12/18/2022] Open
Abstract
Background To investigate the long-term efficacy and safety of empagliflozin monotherapy compared with placebo and sitagliptin in drug-naïve patients with type 2 diabetes mellitus. Methods Of 899 patients randomized to receive empagliflozin 10 mg, empagliflozin 25 mg, placebo, or sitagliptin 100 mg once daily for 24 weeks, 615 continued in a double-blind extension trial for ≥52 weeks. Exploratory endpoints included changes from baseline in HbA1c, weight and blood pressure at week 76. Results Compared with placebo, adjusted mean changes from baseline in HbA1c at week 76 were −0.78 % (95 % CI −0.94, −0.63; p < 0.001) and −0.89 % (95 % CI −1.04, −0.73; p < 0.001) for empagliflozin 10 mg and 25 mg, respectively. Compared with placebo, adjusted mean changes from baseline in weight at week 76 were −1.8 kg (95 % CI −2.4, −1.3; p < 0.001) and −2.0 kg (95 % CI −2.6, −1.5; p < 0.001) for empagliflozin 10 mg and 25 mg, respectively. Empagliflozin led to reductions in systolic blood pressure (SBP) compared with placebo in the primary analysis but not in sensitivity analyses. Compared with sitagliptin, empagliflozin 25 mg reduced HbA1c and both empagliflozin doses reduced weight and SBP. Adverse events (AEs) were reported in 76.8, 78.0, 76.4 and 72.2 % of patients on empagliflozin 10 mg, empagliflozin 25 mg, placebo and sitagliptin, respectively. Confirmed hypoglycaemic AEs (glucose ≤3.9 mmol/l and/or requiring assistance) were reported in two patients (0.9 %) per treatment group. Conclusions Empagliflozin monotherapy for ≥76 weeks was well tolerated and led to sustained reductions in HbA1c and weight compared with placebo. Trial registration: clinicaltrials.gov NCT01289990 Electronic supplementary material The online version of this article (doi:10.1186/s12933-015-0314-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael Roden
- Department of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany. .,Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research, Düsseldorf, Germany. .,German Center for Diabetes Research, Partner Düsseldorf, Düsseldorf, Germany.
| | | | | | - Flavien Roux
- Boehringer Ingelheim France S.A.S., Reims, France.
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA.
| | - Gabriel Kim
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany.
| | - Peter Stella
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany.
| | - Hans J Woerle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany.
| | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany.
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299
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Tan X, Hu J. Combination therapy for type 2 diabetes: dapagliflozin plus metformin. Expert Opin Pharmacother 2015; 17:117-26. [DOI: 10.1517/14656566.2016.1121235] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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300
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Yanai H, Katsuyama H, Hamasaki H, Adachi H, Moriyama S, Yoshikawa R, Sako A. Sodium-Glucose Cotransporter 2 Inhibitors: Possible Anti-Atherosclerotic Effects Beyond Glucose Lowering. J Clin Med Res 2015; 8:10-4. [PMID: 26668677 PMCID: PMC4676340 DOI: 10.14740/jocmr2385w] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2015] [Indexed: 01/10/2023] Open
Abstract
The new drug for type 2 diabetes, the sodium-glucose cotransporter 2 (SGLT-2) inhibitor, is reversible inhibitor of SGLT-2, leading to reduction of renal glucose reabsorption and decrease of plasma glucose, in an insulin-independent manner. In addition to glucose control, the management of coronary risk factors is very important for patients with diabetes. Here we reviewed published articles about the possible anti-atherosclerotic effects beyond glucose lowering of the SGLT-2 inhibitors. We searched by using Pubmed, and found 770 published articles about SGLT-2 inhibitors. Among 10 kinds of SGLT-2 inhibitors, the number of published articles about dapagliflozin was the greatest among SGLT-2 inhibitors. Since SGLT-2 inhibitors have similar chemical structures, we concentrated on the published articles about dapagliflozin. SGLT-2 inhibitors are proved to be significantly associated with weight loss and reduction of blood pressure by a relatively large number of studies. The studies investigating effects of dapagliflozin on visceral fat, insulin sensitivity, serum lipids, inflammation and adipocytokines are very limited. An influence of increase in glucagon secretion by SGLT-2 inhibitors on metabolic risk factors remains unknown.
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Affiliation(s)
- Hidekatsu Yanai
- Department of Internal Medicine, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan
| | - Hisayuki Katsuyama
- Department of Internal Medicine, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan
| | - Hidetaka Hamasaki
- Department of Internal Medicine, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan
| | - Hiroki Adachi
- Department of Internal Medicine, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan
| | - Sumie Moriyama
- Department of Internal Medicine, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan
| | - Reo Yoshikawa
- Department of Internal Medicine, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan
| | - Akahito Sako
- Department of Internal Medicine, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan
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