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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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302
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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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303
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Weber MA, Mansfield TA, Alessi F, Iqbal N, Parikh S, Ptaszynska A. Effects of dapagliflozin on blood pressure in hypertensive diabetic patients on renin-angiotensin system blockade. Blood Press 2015; 25:93-103. [PMID: 26623980 DOI: 10.3109/08037051.2015.1116258] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Hypertension and type 2 diabetes mellitus (T2DM) are risk factors for cardiovascular disease. Dapagliflozin improves glycemic control and systolic blood pressure (SBP) in T2DM patients. This double-blind phase III study evaluated the effects of dapagliflozin on glycemic control and blood pressure in patients with inadequately controlled T2DM and hypertension, despite ongoing therapy with a renin-angiotensin system blocker. Patients were randomized to receive dapagliflozin 10 mg (n = 302) or placebo (n = 311) once daily for 12 weeks. Endpoints were change from baseline to week 12 in seated SBP and glycosylated hemoglobin (HbA1c); longitudinal repeated-measures analysis was performed. Additional endpoints included other hemodynamic measures, serum uric acid, fasting plasma glucose, body weight, blood lipids and heart rate. After 12 weeks, dapagliflozin-treated versus placebo-treated patients showed significant reductions in HbA1c (-0.6% vs -0.1%, p < 0.0001), mean seated SBP (-10.4 vs -7.3 mmHg, p = 0.0010) and mean 24 h ambulatory SBP (-9.6 vs -6.7 mmHg, p = 0.0043). Dapagliflozin also reduced body weight compared with placebo (-1.0 vs -0.3 kg). Dapagliflozin was well tolerated, with adverse events consistent with previous studies. Dapagliflozin improved glycemic control, and reduced SBP as well as body weight in patients with poorly controlled T2DM and hypertension.
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304
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Mudaliar S, Polidori D, Zambrowicz B, Henry RR. Sodium-Glucose Cotransporter Inhibitors: Effects on Renal and Intestinal Glucose Transport: From Bench to Bedside. Diabetes Care 2015; 38:2344-53. [PMID: 26604280 DOI: 10.2337/dc15-0642] [Citation(s) in RCA: 165] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Type 2 diabetes is a chronic disease with disabling micro- and macrovascular complications that lead to excessive morbidity and premature mortality. It affects hundreds of millions of people and imposes an undue economic burden on populations across the world. Although insulin resistance and insulin secretory defects play a major role in the pathogenesis of hyperglycemia, several other metabolic defects contribute to the initiation/worsening of the diabetic state. Prominent among these is increased renal glucose reabsorption, which is maladaptive in patients with diabetes. Instead of an increase in renal glucose excretion, which could ameliorate hyperglycemia, there is an increase in renal glucose reabsorption, which helps sustain hyperglycemia in patients with diabetes. The sodium-glucose cotransporter (SGLT) 2 inhibitors are novel antidiabetes agents that inhibit renal glucose reabsorption and promote glucosuria, thereby leading to reductions in plasma glucose concentrations. In this article, we review the long journey from the discovery of the glucosuric agent phlorizin in the bark of the apple tree through the animal and human studies that led to the development of the current generation of SGLT2 inhibitors.
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Affiliation(s)
- Sunder Mudaliar
- Veterans Affairs Medical Center, San Diego, CA School of Medicine, University of California, San Diego, San Diego, CA
| | | | | | - Robert R Henry
- Veterans Affairs Medical Center, San Diego, CA School of Medicine, University of California, San Diego, San Diego, CA
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305
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Abstract
Type 2 diabetes mellitus (T2DM) is a progressive disease, and most patients ultimately require two or more antidiabetes drugs in addition to lifestyle changes to achieve and maintain glycemic control. Current consensus statements and guidelines recommend metformin as first-line pharmacotherapy for the treatment of T2DM in most patients. When glycemic control cannot be maintained with metformin alone, the sequential, stepwise addition of other agents is recommended. Agents such as thiazolidinediones or sulfonylureas have typically been added to metformin therapy. Although effective in reducing glycated hemoglobin, these drugs are often associated with adverse effects, most notably weight gain, and in the case of sulfonylureas, hypoglycemia. Sodium-glucose cotransporter 2 inhibitors, such as dapagliflozin, are the newest class of antidiabetes drugs approved for the treatment of T2DM. Dapagliflozin effectively improves glycemic control by increasing the renal excretion of excess glucose. In clinical trials, dapagliflozin has been well tolerated and has additional benefits of weight loss, low risk of hypoglycemia and reduction in blood pressure. This review discusses the clinical evidence and rationale for the use of dapagliflozin as add-on therapy in T2DM. The results suggest that dapagliflozin add-on therapy is a promising new treatment option for a wide range of patients with T2DM. Results from an ongoing cardiovascular outcomes trial are needed to establish the long-term safety of dapagliflozin.
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Affiliation(s)
- Tamer Yacoub
- a Endocrinology , Prima Care, P.C ., Fall River , MA , USA
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306
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Liu XY, Zhang N, Chen R, Zhao JG, Yu P. Efficacy and safety of sodium-glucose cotransporter 2 inhibitors in type 2 diabetes: a meta-analysis of randomized controlled trials for 1 to 2years. J Diabetes Complications 2015; 29:1295-303. [PMID: 26365905 DOI: 10.1016/j.jdiacomp.2015.07.011] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 06/16/2015] [Accepted: 07/11/2015] [Indexed: 12/15/2022]
Abstract
AIMS To evaluate the mid long-term efficacy and safety of sodium-glucose cotransporter 2 (SGLT2) inhibitors in adults with type 2 diabetes mellitus (T2DM). METHODS Three databases including Pubmed, Embase, and Cochrane Library were searched for randomized controlled trials (RCTs) of SGLT2 inhibitors that lasted for at least 52weeks. Two reviewers retrieved the literature and evaluated study quality using the Modified Jadad Score Scale. The outcome measures were pooled using random or fixed effects models. RESULTS Fourteen articles of 13 RCTs were included in this meta-analysis. Compared to a placebo, the SGLT2 inhibitors significantly reduced glycated hemoglobin (HbA1c) [for 1year result, weighted mean differences (WMDs): -0.491%; 95% confidence intervals (CIs): -0.573 to -0.410; I(2)=39.9%, for 2years result, WMD: -0.503%; 95% CI: -0.742 to -0.265; I(2)=70.7%], fasting plasma glucose (FPG) (for 1year result, WMD: -0.809; 95% CI: -0.858 to -0.761; I(2)=56.4%; for 2years result, WMD: -0.764; 95% CI: -1.026 to -0.501; I(2)=39.4%), body weight (BW) (for 1year result, WMD: -2.477; 95% CI: -2.568 to -2.385; I(2)=0.0%; for 2years result, WMD: -2.990; 95% CI: -3.642 to -2.337; I(2)=0.0%), systolic blood pressure (SBP) (for 1year result, WMD: -2.874; 95% CI: -4.528 to -1.220; I(2)=98.1%; for 2years result, WMD: -7.500; 95% CI: -7.698 to -7.302) and diastolic blood pressure (DBP) (for 1year result, WMD: -1.950; 95% CI: -2.890 to -1.010; I(2)=98.0%; for 2years result, WMD: -2.197; 95% CI: -3.112 to -1.283). Compared to oral antidiabetic drugs (OADs), the SGLT2 inhibitors also reduced HbA1c, FPG, BW, SBP and DBP significantly. Compared to a placebo, the SGLT2 inhibitors increase the risk of hypoglycemia [odds ratios (ORs): 1.214; 95% CI: 1.036 to 1.423; I(2)=47.7%], urinary infection (OR: 1.477; 95% CI: 1.172 to 1.861; I(2)=46.6%) and genital tract infections (OR: 4.196; 95% CI: 2.332 to 7.549; I(2)=52.7%). Compared to OADs, SGLT2 inhibitors showed a remarkable reduction of hypoglycemia incidence (OR: 0.202; 95% CI: 0.059 to 0.691; I(2)=97.8%), but increased the incidence of genital tract infections (OR: 5.715; 95% CI: 4.339 to 7.528; I(2)=0.0%) and urinary infection (OR: 1.192; 95% CI: 0.990 to 1.434; I(2)=45.3%). SGLT2 inhibitors did not decrease estimated glomerular filtration rate (eGFR) when comparing with placebos [(for absolute value change, WMD: 0.629mL/min/1.73m(2); 95% CI: -1.250 to 2.508; I(2)=0.0%); (for percent change, WMD: -2.274%; 95% CI: -5.410 to 0.861; I(2)=54.5%)] and OADs (for percent change, WMD: 0.356%; 95% CI: -0.967 to 1.679; I(2)=0.0%). CONCLUSION SGLT2 inhibitors have favorable effects on combating hyperglycemia for mid long-term; likewise, they have additional benefits beyond glycemic control such as reducing body weight and lowering blood pressure.
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Affiliation(s)
- Xiang-Yang Liu
- Department of Diabetic Nephropathy Hemodialysis, Key Laboratory of Hormones and Development (Ministry of Health), Metabolic Diseases Hospital & Tianjin Institute of Endocrinology Tianjin Medical University, Tongan Street, Heping District, Tianjin 300070, China
| | - Ning Zhang
- Department of Endocrinology, Chinese PLA No. 254 Hospital, No. 60 Huangwei Road, Hebei District, Tianjin 300142, China
| | - Rui Chen
- Department of Diabetic Nephropathy Hemodialysis, Key Laboratory of Hormones and Development (Ministry of Health), Metabolic Diseases Hospital & Tianjin Institute of Endocrinology Tianjin Medical University, Tongan Street, Heping District, Tianjin 300070, China
| | - Jia-Guo Zhao
- Department of Orthopaedic Surgery, Tianjin Hospital, No. 406 Jiefang South Road, Hexi District, Tianjin 300211, China
| | - Pei Yu
- Department of Diabetic Nephropathy Hemodialysis, Key Laboratory of Hormones and Development (Ministry of Health), Metabolic Diseases Hospital & Tianjin Institute of Endocrinology Tianjin Medical University, Tongan Street, Heping District, Tianjin 300070, China.
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Abstract
INTRODUCTION Inhibitors of sodium-glucose cotransporters type 2 (SGLT2) offer a new opportunity for the management of type 2 diabetes mellitus. These agents reduce hyperglycemia by decreasing the renal glucose threshold and thereby increasing urinary glucose excretion. Subsequent reduction of glucotoxicity improves beta-cell sensitivity to glucose and tissue insulin sensitivity. AREAS COVERED This article analyzes the efficacy and safety data of canagliflozin, dapagliflozin and empagliflozin in randomized controlled trials of 24 - 104 weeks duration, compared with placebo or an active comparator, in patients treated with diet/exercise, metformin, dual oral therapy or insulin. EXPERT OPINION SGLT2 inhibitors significantly and consistently reduce glycated hemoglobin, with a minimal risk of hypoglycemia. The improvement of glucose control is similar or slightly better compared with metformin, sulfonylureas or sitagliptin, with the add-on value of significant reductions in body weight and blood pressure. However, caution is recommended in fragile elderly patients and patients with chronic kidney disease. An increased risk of genital mycotic infections is observed, but urinary tract infections are rare. Concern about an unexpected risk of euglycemic ketoacidosis has been recently reported. A possible renal protection deserves further attention. A remarkable reduction in cardiovascular mortality was reported in EMPA-REG OUTCOME with empagliflozin.
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Affiliation(s)
- André J Scheen
- a Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM) , University of Liège , Liège , Belgium.,b Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine , CHU Liège , Liège B-4000 , Belgium
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308
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Fioretto P, Giaccari A, Sesti G. Efficacy and safety of dapagliflozin, a sodium glucose cotransporter 2 (SGLT2) inhibitor, in diabetes mellitus. Cardiovasc Diabetol 2015; 14:142. [PMID: 26474563 PMCID: PMC4609166 DOI: 10.1186/s12933-015-0297-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/25/2015] [Indexed: 02/07/2023] Open
Abstract
Although antidiabetic agents have been developed to target one or more of the core defects of type 2 diabetes mellitus (T2DM), many patients do not achieve glycemic goals. Inhibition of the sodium-glucose cotransporter 2 (SGLT2) induces glycosuria, reduces glucose toxicity and improves insulin sensitivity and β-cell function. As the mechanism of action of SGLT2 inhibitors is different from other agents and completely insulin-independent, the use of these drugs might potentially be efficacious alone or in combination with any other antidiabetic drug, including insulin. Dapagliflozin is a highly selective and reversible SGLT2 inhibitor approved for use in adult patients with T2DM as monotherapy in patients intolerant of metformin or as adjunctive therapy in patients inadequately controlled on existing antidiabetic medications, including insulin. A literature search conducted using PubMed identified key publications related to the use of dapagliflozin in the treatment of patients with diabetes mellitus. No date limits were applied. This review focuses on the safety and efficacy of this SGLT2 inhibitor. Dapagliflozin produces dose-related reductions in glycosylated hemoglobin (HbA1c) as monotherapy and as add-on to other antidiabetic agents, with significant reductions in body weight. Hypoglycemia is uncommon. Preliminary data from a phase 2 pharmacokinetic/pharmacodynamic study suggest that dapagliflozin may also improve glycemic control in patients with type 1 diabetes mellitus. Clinical trials published to date show that dapagliflozin is safe and effective as monotherapy or as an add-on to insulin or oral antidiabetic agents in patients with T2DM.
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Affiliation(s)
- Paola Fioretto
- Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.
| | - Andrea Giaccari
- EndoMetabolic Diseases Unit, Policlinico Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - Giorgio Sesti
- Department of Medical and Surgical Sciences, University Magna-Græcia of Catanzaro, Viale Europa, 88100, Catanzaro, Italy.
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309
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Vivian E. Sodium-Glucose Cotransporter 2 Inhibitors in the Treatment of Type 2 Diabetes Mellitus. DIABETES EDUCATOR 2015; 41:5S-18S. [DOI: 10.1177/0145721715607643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Purpose The purpose of this review article is to provide guidance to clinicians and diabetes educators regarding the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors as a therapeutic option for the treatment of patients with type 2 diabetes mellitus (T2DM). Methods The PubMed database was searched through February 2015 to identify clinical trials and meta-analyses evaluating the use of the SGLT2 inhibitors canagliflozin, dapagliflozin, and empagliflozin administered as monotherapy or in combination with other oral antidiabetes drugs or with insulin. Results SGLT2 inhibitors reduce hyperglycemia in an insulin-independent manner by inhibiting the reabsorption of glucose into the systemic circulation by the kidneys. In patients with T2DM, SGLT2 inhibitors provide consistent reductions in glycated hemoglobin, fasting plasma and postprandial glucose, body weight, and blood pressure when used as monotherapy or in combination with other oral antidiabetes agents or with insulin. SGLT2 inhibitors are associated with a low risk of hypoglycemia, except when used with agents known to be associated with a higher risk of hypoglycemia, such as sulfonylureas or insulin. Conclusions The unique renal-specific mechanism of action and favorable efficacy and safety profile of SGLT2 inhibitors support consideration of these antidiabetes agents as a treatment option for patients with T2DM.
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Affiliation(s)
- Eva Vivian
- School of Pharmacy, University of Wisconsin, Madison, Wisconsin (Dr Vivian)
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310
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Brunton SA. The potential role of sodium glucose co-transporter 2 inhibitors in the early treatment of type 2 diabetes mellitus. Int J Clin Pract 2015; 69:1071-87. [PMID: 26147213 PMCID: PMC4758393 DOI: 10.1111/ijcp.12675] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Sodium glucose co-transporter 2 (SGLT2) inhibitors are a new class of pharmacologic agents developed for the treatment of type 2 diabetes mellitus (T2DM). Their unique mechanism of action is independent of pancreatic beta-cell function or the degree of insulin resistance, giving these agents the potential for use in combination with any of the existing classes of glucose-lowering agents, including insulin. This makes SGLT2 inhibitors an option for patients with long-standing T2DM, but they also have a promising role for early intervention in T2DM, and that role is explored in this review. METHODS A literature search was performed to identify relevant English language articles relating to SGLT2 inhibitors, particularly dapagliflozin, canagliflozin and empagliflozin. RESULTS Clinical trials of dapagliflozin, canagliflozin and empagliflozin, given as monotherapy or in combination with other glucose-lowering agents, reported clinically significant improvements in glycaemic control, body weight and systolic blood pressure. SGLT2 inhibitors were well tolerated and had a generally favourable safety profile. Few serious adverse events have been reported to date. The frequency of hypoglycaemic events was low, similar to that of placebo, and the choice of co-administered glucose-lowering agent was the major determinant of hypoglycaemic risk. Increased genital and urinary tract infections were consistently reported with SGLT2 inhibitors. CONCLUSIONS SGLT2 inhibitors, with their unique insulin-independent mode of action, could have a significant impact on the early management of T2DM, by addressing some of the specific risk factors associated with this disease. SGLT2 inhibitors induce beneficial changes in a number of cardiovascular risk factors, such as lowering blood pressure and body weight, in addition to improved glycaemic control, although information on clinical cardiovascular outcomes is currently limited.
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Affiliation(s)
- S A Brunton
- Primary Care Metabolic Group, Charlotte, NC, USA
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311
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Pharmacodynamics, efficacy and safety of sodium-glucose co-transporter type 2 (SGLT2) inhibitors for the treatment of type 2 diabetes mellitus. Drugs 2015; 75:33-59. [PMID: 25488697 DOI: 10.1007/s40265-014-0337-y] [Citation(s) in RCA: 358] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Inhibitors of sodium-glucose co-transporter type 2 (SGLT2) are proposed as a novel approach for the management of type 2 diabetes mellitus (T2DM). Several compounds are already available in many countries (dapagliflozin, canagliflozin, empagliflozin and ipragliflozin) and some others are in a late phase of development. The available SGLT2 inhibitors share similar pharmacokinetic characteristics, with a rapid oral absorption, a long elimination half-life allowing once-daily administration, an extensive hepatic metabolism mainly via glucuronidation to inactive metabolites, the absence of clinically relevant drug-drug interactions and a low renal elimination as parent drug. SGLT2 co-transporters are responsible for reabsorption of most (90 %) of the glucose filtered by the kidneys. The pharmacological inhibition of SGLT2 co-transporters reduces hyperglycaemia by decreasing renal glucose threshold and thereby increasing urinary glucose excretion. The amount of glucose excreted in the urine depends on both the level of hyperglycaemia and the glomerular filtration rate. Results of numerous placebo-controlled randomised clinical trials of 12-104 weeks duration have shown significant reductions in glycated haemoglobin (HbA1c), resulting in a significant increase in the proportion of patients reaching HbA1c targets, and a significant lowering of fasting plasma glucose when SGLT2 inhibitors were administered as monotherapy or in addition to other glucose-lowering therapies including insulin in patients with T2DM. In head-to-head trials of up to 2 years, SGLT2 inhibitors exerted similar glucose-lowering activity to metformin, sulphonylureas or sitagliptin. The durability of the glucose-lowering effect of SGLT2 inhibitors appears to be better; however, this remains to be more extensively investigated. The risk of hypoglycaemia was much lower with SGLT2 inhibitors than with sulphonylureas and was similarly low as that reported with metformin, pioglitazone or sitagliptin. Increased renal glucose elimination also assists weight loss and could help to reduce blood pressure. Both effects were very consistent across the trials and they represent some advantages for SGLT2 inhibitors when compared with other oral glucose-lowering agents. The pharmacodynamic response to SGLT2 inhibitors declines with increasing severity of renal impairment, and prescribing information for each SGLT2 inhibitor should be consulted regarding dosage adjustments or restrictions in moderate to severe renal dysfunction. Caution is also recommended in the elderly population because of a higher risk of renal impairment, orthostatic hypotension and dehydration, even if the absence of hypoglycaemia represents an obvious advantage in this population. The overall effect of SGLT2 inhibitors on the risk of cardiovascular disease is unknown and will be evaluated in several ongoing prospective placebo-controlled trials with cardiovascular outcomes. The impact of SGLT2 inhibitors on renal function and their potential to influence the course of diabetic nephropathy also deserve more attention. SGLT2 inhibitors are generally well-tolerated. The most frequently reported adverse events are female genital mycotic infections, while urinary tract infections are less commonly observed and generally benign. In conclusion, with their unique mechanism of action that is independent of insulin secretion and action, SGLT2 inhibitors are a useful addition to the therapeutic options available for the management of T2DM at any stage in the natural history of the disease. Although SGLT2 inhibitors have already been extensively investigated, further studies should even better delineate the best place of these new glucose-lowering agents in the already rich armamentarium for the management of T2DM.
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312
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Sjöström CD, Hashemi M, Sugg J, Ptaszynska A, Johnsson E. Dapagliflozin-induced weight loss affects 24-week glycated haemoglobin and blood pressure levels. Diabetes Obes Metab 2015; 17:809-12. [PMID: 25997813 DOI: 10.1111/dom.12500] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 05/12/2015] [Accepted: 05/18/2015] [Indexed: 12/20/2022]
Abstract
The aim of this study was to investigate the associations between dapagliflozin-mediated reductions in body weight and reductions in glycated haemoglobin (HbA1c) and blood pressure. Data were pooled from seven studies evaluating dapagliflozin 10 mg as monotherapy or combination therapy over 24 weeks. Using linear regression to estimate the contribution of weight loss to HbA1c and blood pressure reductions, the β-value estimate for HbA1c (%)/kg was 0.028 (p < 0.0001). Weight loss of 2 kg with dapagliflozin contributed to 6% of the total HbA1c reduction. For systolic (SBP) and diastolic blood pressure (DBP), the β-value (mmHg/kg) estimates were 0.606 (p < 0.0001) and 0.253 (p < 0.0001), respectively. Weight loss of 2 kg contributed to 28% of the overall SBP reduction, and 24% of the overall DBP reduction. In conclusion, dapagliflozin-mediated weight loss may contribute to overall reductions in HbA1c and blood pressure.
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Affiliation(s)
| | | | - J Sugg
- Formerly AstraZeneca, Wilmington, DE, USA
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Harper W, Clement M, Goldenberg R, Hanna A, Main A, Retnakaran R, Sherifali D, Woo V, Yale JF, Cheng AY. Policies, Guidelines and Consensus Statements: Pharmacologic Management of Type 2 Diabetes–2015 Interim Update. Can J Diabetes 2015; 39:250-2. [DOI: 10.1016/j.jcjd.2015.05.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 05/13/2015] [Indexed: 02/06/2023]
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314
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Scheen AJ, Paquot N. Metabolic effects of SGLT-2 inhibitors beyond increased glucosuria: A review of the clinical evidence. DIABETES & METABOLISM 2015; 40:S4-S11. [PMID: 25554070 DOI: 10.1016/s1262-3636(14)72689-8] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Sodium-glucose cotransporter type 2 (SGLT-2) inhibitors (canagliflozin, dapagliflozin, empagliflozin) are new glucose-lowering agents that exert their therapeutic activity independently of insulin by facilitating glucose excretion through the kidneys. However, this simple renal mechanism that results in sustained glucose urinary loss leads to more complex indirect metabolic effects. First, by reduction of chronic hyperglycaemia and attenuation of glucose toxicity, SGLT-2 inhibitors can improve both insulin secretion by beta cells and peripheraltissue insulin sensitivity. In the case of canagliflozin, because of low-potency SGLT1 inhibition, a non-renal (intestinal) effect may also be considered, which may contribute to better control of postprandial hyperglycaemia, although this contribution remains to be better analyzed in humans. Second, chronic glucose loss most probably leads to compensatory mechanisms. One of them, although not well evidenced in humans, might involve an increase in energy intake, an effect that may limit weight loss in the long run. Another could be an increase in endogenous glucose production, most probably driven by increased glucagon secretion, which may somewhat attenuate the glucoselowering effect. Nevertheless, despite these compensatory mechanisms and most probably because of the positive effects of the reduction in glucotoxicity, SGLT-2 inhibitors exert clinically relevant glucose-lowering activity while promoting weight loss, a unique dual effect among oral antidiabetic agents. Furthermore, the combination of SGLT-2 inhibitors with other drugs that either have anorectic effects (such as incretin-based therapies) or reduce hepatic glucose output (like metformin) and, thus, may dampen these two compensatory mechanisms appears appealing for the management of type 2 diabetes mellitus.
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Affiliation(s)
- A J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, University of Liège, Liège, Belgium; Clinical Pharmacology Unit, CHU Liège, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
| | - N Paquot
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, University of Liège, Liège, Belgium; Diabetology and Nutrition, GIGA I3, University of Liège, Liège, Belgium
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315
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Riggs K, Ali H, Taegtmeyer H, Gutierrez AD. The Use of SGLT-2 Inhibitors in Type 2 Diabetes and Heart Failure. Metab Syndr Relat Disord 2015; 13:292-7. [PMID: 26125313 DOI: 10.1089/met.2015.0038] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The concurrent management of type 2 diabetes mellitus (T2DM) and chronic congestive heart failure presents several therapeutic challenges. Of concern is that insulin and insulin-sensitizing medications detrimentally "flood" the heart with energy-providing substrates, including fats and glucose. In this population, treatment of T2DM should focus on the reduction of increased substrate supply. Sodium glucose cotransporter-2 (SGLT-2) inhibitors, a new class of antidiabetic medication, operate via this principle by blocking the reabsorption of glucose in the kidney and subsequently releasing glucose through the urine. In this review, we begin with an examination of the mechanisms of glucotoxicity and lipotoxicity in the heart. Then we analyze the potential role of SGLT-2 inhibitor therapy in patients with concurrent T2DM and chronic heart failure. Based on the available evidence, SGLT-2 inhibitors are safe and can be recommended to treat T2DM in patients with chronic heart failure and intact renal function. Further studies are in progress to assess long-term survival benefits.
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Affiliation(s)
- Kayla Riggs
- 1 Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Texas Health Science Center at Houston School of Medicine , Houston, Texas
| | - Hiba Ali
- 1 Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Texas Health Science Center at Houston School of Medicine , Houston, Texas
| | - Heinrich Taegtmeyer
- 2 Division of Cardiology, Department of Medicine, University of Texas Health Science Center at Houston School of Medicine , Houston, Texas
| | - Absalon D Gutierrez
- 1 Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Texas Health Science Center at Houston School of Medicine , Houston, Texas
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316
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Van Gaal L, Scheen A. Weight management in type 2 diabetes: current and emerging approaches to treatment. Diabetes Care 2015; 38:1161-72. [PMID: 25998297 DOI: 10.2337/dc14-1630] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Diabetes is a growing global health concern, as is obesity. Diabetes and obesity are intrinsically linked: obesity increases the risk of diabetes and also contributes to disease progression and cardiovascular disease. Although the benefits of weight loss in the prevention of diabetes and as a critical component of managing the condition are well established, weight reduction remains challenging for individuals with type 2 diabetes due to a host of metabolic and psychological factors. For many patients, lifestyle intervention is not enough to achieve weight loss, and alternative options, such as pharmacotherapy, need to be considered. However, many traditional glucose-lowering medications may lead to weight gain. This article focuses on the potential of currently available pharmacological strategies and on emerging approaches in development to support the glycemic and weight-loss goals of individuals with type 2 diabetes. Two pharmacotherapy types are considered: those developed primarily for blood glucose control that have a favorable effect on body weight and those developed primarily to induce weight loss that have a favorable effect on blood glucose control. Finally, the potential of combination therapies for the management of obese patients with type 2 diabetes is discussed.
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Affiliation(s)
- Luc Van Gaal
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Antwerp, Belgium
| | - André Scheen
- Department of Diabetes, Nutrition and Metabolic Disorders and Clinical Pharmacology Unit, University of Liège, Liège, Belgium
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317
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Hinnen D. Glucuretic effects and renal safety of dapagliflozin in patients with type 2 diabetes. Ther Adv Endocrinol Metab 2015; 6:92-102. [PMID: 26137213 PMCID: PMC4480550 DOI: 10.1177/2042018815575273] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Dapagliflozin is a selective sodium-glucose cotransporter 2 (SGLT2) inhibitor approved as a treatment for type 2 diabetes mellitus (T2DM) in the United States, the European Union and other countries. Dapagliflozin increases renal glucose excretion in an insulin-independent manner, and its mechanism of action is complementary to those of other antidiabetes medications. When used as monotherapy or in combination with other oral antidiabetes medications or insulin, dapagliflozin improves glycemic measures in patients with T2DM. Dapagliflozin treatment is also associated with weight reduction and a decrease in blood pressure, both of which may be beneficial in patients with T2DM. Because of its mechanism of action, dapagliflozin has a low intrinsic propensity to cause hypoglycemia. Overall, dapagliflozin is well tolerated, with the frequency of most adverse events similar to that seen with placebo. Cases of genital infections and, in some studies, urinary tract infections have been more frequent in dapagliflozin-treated groups compared with placebo groups. In the clinical development program, more cases of newly diagnosed bladder cancer were reported for patients treated with dapagliflozin (0.17%) compared with placebo or comparator (0.03%). Although there were not enough cases to determine causality, dapagliflozin should not be used in patients with bladder cancer and should be used with caution in patients with a history of bladder cancer. Dapagliflozin may decrease glomerular filtration rate (GFR), especially in elderly patients and patients with impaired renal function. Renal function should be monitored before initiation of dapagliflozin. Dapagliflozin should not be used in patients with an estimated GFR <60 ml/min/1.73 m(2). No cardiovascular safety signals have been detected for dapagliflozin, and a long-term cardiovascular outcomes study is ongoing. Evidence from clinical trials suggests that dapagliflozin is a promising new treatment option for T2DM.
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Affiliation(s)
- Deborah Hinnen
- Memorial Hospital Diabetes Center, University of Colorado Health, 175 South Union Boulevard, Suite 305, Colorado Springs, CO 80190, USA
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318
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Cornell S. Continual evolution of type 2 diabetes: an update on pathophysiology and emerging treatment options. Ther Clin Risk Manag 2015; 11:621-32. [PMID: 25931824 PMCID: PMC4404882 DOI: 10.2147/tcrm.s67387] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Diabetes is a complex and progressive disease that has a major societal and economic impact. The most common form of diabetes, type 2 diabetes mellitus (T2DM), is a multifactorial disease, the pathophysiology of which involves not only the pancreas but also the liver, skeletal muscle, adipose tissue, gastrointestinal tract, brain, and kidney. Novel therapies with mechanisms of action that are different from most existing drugs are emerging. One such class consists of compounds that inhibit renal sodium-glucose cotransporter 2, which is responsible for the bulk of glucose reabsorption by the kidneys. This new class of compounds improves glycemic control independently of insulin and promotes weight reduction, providing an additional tool to treat patients with T2DM. This review discusses the underlying pathophysiology of T2DM, clinical guidelines, and available and emerging treatment options, with particular emphasis on sodium-glucose cotransporter 2 inhibitors.
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Affiliation(s)
- Susan Cornell
- Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
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319
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Abstract
Patients with type 2 diabetes mellitus (T2DM) have an increased risk of fragility fractures despite increased body weight and normal or higher bone mineral density. The mechanisms by which T2DM increases skeletal fragility are unclear. It is likely that a combination of factors, including a greater risk of falling, regional osteopenia, and impaired bone quality, contributes to the increased fracture risk. Drugs for the treatment of T2DM may also impact on the risk for fractures. For example, thiazolidinediones accelerate bone loss and increase the risk of fractures, particularly in older women. In contrast, metformin and sulfonylureas do not appear to have a negative effect on bone health and may, in fact, protect against fragility fracture. Animal models indicate a potential role for incretin hormones in bone metabolism, but there are only limited data on the impact of dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 agonists on bone health in humans. Animal models also have demonstrated a role for amylin in bone metabolism, but clinical trials in patients with type 1 diabetes with an amylin analog (pramlintide) have not shown a significant impact on bone metabolism. The effects of insulin treatment on fracture risk are inconsistent with some studies showing an increased risk and others showing no effect. Finally, although there is limited information on the latest class of medications for the treatment of T2DM, the sodium-glucose co-transporter-2 inhibitors, these drugs do not seem to increase fracture risk. Because diabetes is an increasingly common chronic condition that can affect patients for many decades, further research into the effects of agents for the treatment of T2DM on bone metabolism is warranted. In this review, the physiological mechanisms and clinical impact of diabetes treatments on bone health and fracture risk in patients with T2DM are described.
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Affiliation(s)
- Matthew P Gilbert
- Division of Endocrinology and Diabetes (M.P.G.), The University of Vermont College of Medicine, Burlington, Vermont 05405; and Florida Hospital Diabetes and Translational Research Institutes and Sanford-Burnham Medical Research Institute, Orlando, Florida 32827
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320
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Abstract
Sodium glucose cotransporter type 2 (SGLT2) inhibitors are a new class of drug developed to treat type 2 diabetes mellitus (T2DM). They target the kidney by reducing renal glucose reabsorption and promoting urinary glucose excretion, which reduces hyperglycemia in individuals with T2DM. The SGLT2 inhibitor empagliflozin has gained approval in the EU and in the USA for the treatment of adults with T2DM (there is no current indication in type 1 diabetes). Empagliflozin has shown a good efficacy and safety profile from clinical trials when given as monotherapy, and as an add-on therapy to other glucose-lowering agents. This short commentary reviews the key efficacy and safety data from empagliflozin phase III trials and examines the potential role this agent may have in the management of T2DM.
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Affiliation(s)
- Deborah Hinnen
- Memorial Hospital Diabetes Center University of Colorado Health 175 S. Union Boulevard, Suite 305 Colorado Springs, CO 80910 USA
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321
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Inzucchi SE, Zinman B, Wanner C, Ferrari R, Fitchett D, Hantel S, Espadero RM, Woerle HJ, Broedl UC, Johansen OE. SGLT-2 inhibitors and cardiovascular risk: proposed pathways and review of ongoing outcome trials. Diab Vasc Dis Res 2015; 12:90-100. [PMID: 25589482 PMCID: PMC4361459 DOI: 10.1177/1479164114559852] [Citation(s) in RCA: 286] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Given the multi-faceted pathogenesis of atherosclerosis in type 2 diabetes mellitus (T2DM), it is likely that interventions to mitigate this risk must address cardiovascular (CV) risk factors beyond glucose itself. Sodium glucose cotransporter-2 (SGLT-2) inhibitors are newer antihyperglycaemic agents with apparent multiple effects. Inherent in their mode of action to decrease glucose reabsorption by the kidneys by increasing urinary glucose excretion, these agents improve glycaemic control independent of insulin secretion with a low risk of hypoglycaemia. In this review, we outline those CV risk factors that this class appears to influence and provide the design features and trial characteristics of six ongoing outcome trials involving more than 41,000 individuals with T2DM. Those risk factors beyond glucose that can potentially be modulated positively with SGLT-2 inhibitors include blood pressure, weight, visceral adiposity, hyperinsulinaemia, arterial stiffness, albuminuria, circulating uric acid levels and oxidative stress. On the other hand, small increases in low-density lipoprotein (LDL)-cholesterol levels have also been observed for the class, which theoretically might offset some of these benefits. The potential translational impact of these effects is being tested with outcome trials, also reviewed in this article, powered to assess both macrovascular as well as certain microvascular outcomes in T2DM. These are expected to begin to report in late 2015.
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Affiliation(s)
- Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, CT, USA
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Christoph Wanner
- Division of Nephrology, University of Würzburg, Würzburg, Germany
| | - Roberto Ferrari
- Department of Cardiology and LTTA Centre, University Hospital of Ferrara, Ferrara, Italy Maria Cecilia Hospital, GVM Care & Research, E.S: Health Science Foundation, Cotignola, Italy
| | - David Fitchett
- St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Stefan Hantel
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | | | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
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322
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Abstract
There are several mechanisms by which diabetes could affect bone mass and strength. These mechanisms include insulin deficiency; hyperglycemia; the accumulation of advanced glycation end products that may influence collagen characteristics; marrow adiposity and bone inflammation. Furthermore, associated diabetic complications and treatment with thaizolidinediones may also increase risk of fracturing. The following article provides its readers with an update on the latest information pertaining to diabetes related bone skeletal fragility. In the authors' opinion, future studies are needed in order to clarify the impact of different aspects of diabetes metabolism, glycemic control, and specific treatments for diabetes on bone. Given that dual energy x-ray absorptiometry is a poor predictor of bone morbidity in this group of patients, there is a need to explore novel approaches for assessing bone quality. It is important that we develop a better understanding of how diabetes affects bone in order to improve our ability to protect bone health and prevent fractures in the growing population of adults with diabetes.
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Affiliation(s)
- Naiemh Abdalrahman
- a Developmental Endocrinology Research Group, Royal Hospital for Sick Children, School of Medicine, University of Glasgow, Yorkhill, Glasgow G3 8SJ, UK
| | - Suet Ching Chen
- a Developmental Endocrinology Research Group, Royal Hospital for Sick Children, School of Medicine, University of Glasgow, Yorkhill, Glasgow G3 8SJ, UK
| | - Jessie Ruijun Wang
- a Developmental Endocrinology Research Group, Royal Hospital for Sick Children, School of Medicine, University of Glasgow, Yorkhill, Glasgow G3 8SJ, UK
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323
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Impact of Anti-hyperglycemic Medications on Bone Health. Clin Rev Bone Miner Metab 2015. [DOI: 10.1007/s12018-015-9176-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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324
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Abstract
Type 2 diabetes mellitus (T2DM) is a common chronic disease that may be associated with an increased risk of fracture. Evidence that thiazolidinediones (TZDs) increase fracture risk in women with T2DM has focused attention on the skeletal effects of treatments for diabetes. Only scant, low-quality evidence is available for non-TZD diabetes medications and bone health, but it suggests that there are no clinically important effects.
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Affiliation(s)
- Andrew Grey
- Department of Medicine, University of Auckland, Private Bag 92019, Auckland, New Zealand,
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325
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Filippatos TD, Liberopoulos EN, Elisaf MS. Dapagliflozin in patients with type 2 diabetes mellitus. Ther Adv Endocrinol Metab 2015; 6:29-41. [PMID: 25678954 PMCID: PMC4321869 DOI: 10.1177/2042018814558243] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Dapagliflozin is a selective and reversible inhibitor of sodium-glucose linked transporter type 2 (SGLT2), which mediates approximately 90% of active renal glucose reabsorption in the early proximal tubule of the kidney. Dapagliflozin significantly reduces glucose reabsorption and decreases serum glucose concentration in an insulin-independent manner. The decrease of glucose reabsorption by dapagliflozin has also been associated with a reduction in body weight. Furthermore, the drug modestly reduces blood pressure levels through weight loss and its action as osmotic diuretic. Dapagliflozin has been approved as monotherapy in patients with type 2 diabetes mellitus (T2DM) who cannot tolerate metformin or in combination with other antidiabetic drugs, with the exception of pioglitazone due to the theoretical increased risk of bladder cancer. The drug should not be prescribed in patients with moderate or severe renal impairment or in patients at risk for developing volume depletion. Dapagliflozin is associated with increased incidence of genital and lower urinary tract infections, but these infections are usually mild to moderate and respond to standard antimicrobial treatment. Based on current evidence, dapagliflozin is a useful drug for patients with T2DM with a favorable safety profile. However, further research regarding the effects of dapagliflozin on cardiovascular outcomes is needed.
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Affiliation(s)
- Theodosios D Filippatos
- Assistant Professor of Internal Medicine Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Evangelos N Liberopoulos
- Assistant Professor of Internal Medicine 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, 45 110 Ioannina, Greece
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326
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Sanz-Serra P, Pedro-Botet J, Flores-Le Roux JA, Benaiges D, Chillarón JJ. [Dapagliflozin: Beyond glycemic control in the treatment of type 2 diabetes mellitus]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2015; 27:205-11. [PMID: 25648671 DOI: 10.1016/j.arteri.2014.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 11/19/2014] [Indexed: 02/06/2023]
Abstract
Patients with type 2 diabetes mellitus (T2DM) have a high or very high cardiovascular risk. The clinical practice guidelines focus on the need to achieve optimal glycemic control, and strategies for a multifactorial therapeutic approach have shown significant cardiovascular benefits in these patients. Inhibitors of sodium-glucose co-transporter 2 (SGLT-2) are a new class of orally administered drugs in the treatment of T2DM, which act by inhibiting reabsorption of glucose in the renal proximal tubule with consequent glycosuric effect and lowering of blood glucose. Dapagliflozin, SGLT-2 inhibitor marketed in Europe and Australia, has been shown to achieve glycosylated hemoglobin reductions similar to other oral agents, as well as beneficial effects on major comorbidities associated with T2DM. Therefore, it is considered of interest to review the clinical efficacy of this new oral hypoglycemic on glycemic control, risk of hypoglycemia, and its impact on body weight, blood pressure, lipid profile and renal function.
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Affiliation(s)
- Pol Sanz-Serra
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Barcelona, España; Departamento de Medicina, Universitat de Barcelona, Barcelona, España
| | - Juan Pedro-Botet
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Barcelona, España; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, España.
| | - Juana A Flores-Le Roux
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Barcelona, España; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, España
| | - David Benaiges
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Barcelona, España; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, España
| | - Juan J Chillarón
- Unidad de Lípidos y Riesgo Vascular, Servicio de Endocrinología y Nutrición, Hospital del Mar, Barcelona, España; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, España
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327
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Abstract
Meta-analyses have revealed that the relative risk of hip fractures in patients with type 1 and type 2 diabetes mellitus is higher than that in non-diabetic subjects. The risk of fracture in patients with diabetes mellitus increases along with a decrease in bone mineral density (BMD) similarly to those in non-diabetic patients. However, the observed risk of fracture is higher than expected one by BMD in both type 1 and type 2 diabetic patients, indicating that precise estimation of bone fragility by BMD values in patients with diabetes is difficult. Bone strength consists of BMD and bone quality, for this reason, poor bone quality is a most suitable and explicable cause for elevated fracture risk in this population. This bone fragility observed in patients with diabetes mellitus is caused by unique pathogenesis in diabetes, suggesting that osteoporosis in diabetic patients may be one of the diabetic complications and that specific diagnostic criteria for this osteoporosis is required. Bone quality indicators closely related to bone fragility are required to be identified to establish a diagnostic method for osteoporosis in patients with diabetes mellitus.
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Affiliation(s)
- Masahiro Yamamoto
- Internal Medicine 1, Shimane University Faculty of Medicine, Izumo 693-8501, Japan
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328
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Vivian EM. Sodium-glucose co-transporter 2 (SGLT2) inhibitors: a growing class of antidiabetic agents. Drugs Context 2014; 3:212264. [PMID: 25598831 PMCID: PMC4295914 DOI: 10.7573/dic.212264] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 11/10/2014] [Accepted: 09/04/2014] [Indexed: 12/20/2022] Open
Abstract
Although several treatment options are available to reduce hyperglycemia, only about half of individuals with diagnosed diabetes mellitus (DM) achieve recommended glycemic targets. New agents that reduce blood glucose concentrations by novel mechanisms and have acceptable safety profiles are needed to improve glycemic control and reduce the complications associated with type 2 diabetes mellitus (T2DM). The renal sodium-glucose co-transporter 2 (SGLT2) is responsible for reabsorption of most of the glucose filtered by the kidney. Inhibitors of SGLT2 lower blood glucose independent of the secretion and action of insulin by inhibiting renal reabsorption of glucose, thereby promoting the increased urinary excretion of excess glucose. Canagliflozin, dapagliflozin, and empagliflozin are SGLT2 inhibitors approved as treatments for T2DM in the United States, Europe, and other countries. Canagliflozin, dapagliflozin, and empagliflozin increase renal excretion of glucose and improve glycemic parameters in patients with T2DM when used as monotherapy or in combination with other antihyperglycemic agents. Treatment with SGLT2 inhibitors is associated with weight reduction, lowered blood pressure, and a low intrinsic propensity to cause hypoglycemia. Overall, canagliflozin, dapagliflozin, and empagliflozin are well tolerated. Cases of genital infections and, in some studies, urinary tract infections have been more frequent in canagliflozin-, dapagliflozin-, and empagliflozin-treated patients compared with those receiving placebo. Evidence from clinical trials suggests that SGLT2 inhibitors are a promising new treatment option for T2DM.
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Affiliation(s)
- Eva M Vivian
- School of Pharmacy, University of Wisconsin, Madison, WI, USA
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329
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Saeed MA, Narendran P. Dapagliflozin for the treatment of type 2 diabetes: a review of the literature. Drug Des Devel Ther 2014; 8:2493-505. [PMID: 25525338 PMCID: PMC4267514 DOI: 10.2147/dddt.s50963] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Dapagliflozin was the first drug in a class of therapies that took a new approach to glycemic control in adults with type 2 diabetes (T2D). It is an inhibitor of the sodium glucose cotransporter, resident in the proximal nephron, which is responsible for the recovery of filtered glucose back into circulation. Inhibiting this cotransporter reduces glucose recovery, increases glucose excretion, and reduces hyperglycemia. Here, we review some of the literature relating to the action, efficacy, and clinical use of dapagliflozin. MATERIALS AND METHODS A Medline search was conducted within date, animal, and language limits, and relevant papers were selected for review. Conference proceedings were reviewed to obtain up-to-date literature on this drug. Clinical trial websites were reviewed for ongoing studies. RESULTS On average, treatment with dapagliflozin results in improvement in glycated hemoglobin by 0.50%, fasting plasma glucose by 1 mmol/L, weight by 2 kg, body mass index by 1.1%, and systolic/diastolic blood pressure by 4/2 mmHg over 24-52 weeks. The weight benefit is greater when used in association with sulfonylureas. It is generally well tolerated, but comes with an increased risk of genitourinary and urinary tract infections. In addition, it is associated with reversible changes to renal function that need to be explored. Early reports of an association with cancer also need to be carefully monitored. CONCLUSION Dapagliflozin is a useful therapy for adult patients with T2D. It also holds potential for a broader range of patients with T2D (such as the elderly and pediatric populations), as well as those with other forms of diabetes, such as type 1 diabetes. While longer-term outcome studies of safety and efficacy are awaited, dapagliflozin forms a very useful and welcome addition to our armamentarium for managing patients with T2D.
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Affiliation(s)
- Mujahid A Saeed
- Department of Diabetes, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Parth Narendran
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
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330
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Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are sent in print and are also available on-line. Monographs can be customized to meet the needs of a facility. A drug class review is now published monthly with The Formulary Monograph Service. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, call The Formulary at 800-322-4349. The July 2014 monograph topics are albiglutide, ramucirumab, short ragweed pollen allergen extract, timothy grass pollen allergen extract, and isavuconazole. The DUE/MUE is on albiglutide.
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Affiliation(s)
- Dennis J Cada
- Founder and Contributing Editor, The Formulary , Washington State University , Spokane, Washington
| | - Terri L Levien
- Clinical Professor, Drug Information Center, Washington State University , Spokane, Washington
| | - Danial E Baker
- Director, Drug Information Center, and Professor of Pharmacy Practice, College of Pharmacy , Washington State University Spokane, PO Box 1495, Spokane, Washington 99210-1495 . The authors indicate no relationships that could be perceived as a conflict of interest
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331
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Kalra S. Sodium Glucose Co-Transporter-2 (SGLT2) Inhibitors: A Review of Their Basic and Clinical Pharmacology. Diabetes Ther 2014; 5:355-66. [PMID: 25424969 PMCID: PMC4269649 DOI: 10.1007/s13300-014-0089-4] [Citation(s) in RCA: 200] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Indexed: 02/06/2023] Open
Abstract
Sodium-glucose co-transporter-2 (SGLT2) inhibitors are a newly developed class of oral anti-diabetic drugs (OADs) with a unique mechanism of action. This review describes the biochemistry and physiology underlying the use of SGLT2 inhibitors, and their clinical pharmacology, including mechanism of action and posology. The pragmatic placement of these molecules in the existing OAD arena is also discussed.
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332
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Barbosa MD, Smith DD. Channeling postmarketing patient data into pharmaceutical regulatory systems. Drug Discov Today 2014; 19:1897-912. [DOI: 10.1016/j.drudis.2014.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/24/2014] [Accepted: 07/24/2014] [Indexed: 12/15/2022]
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333
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Kaku K, Maegawa H, Tanizawa Y, Kiyosue A, Ide Y, Tokudome T, Hoshino Y, Yang J, Langkilde AM. Dapagliflozin as monotherapy or combination therapy in Japanese patients with type 2 diabetes: an open-label study. Diabetes Ther 2014; 5:415-33. [PMID: 25341477 PMCID: PMC4269643 DOI: 10.1007/s13300-014-0086-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Dapagliflozin is a selective sodium glucose co-transporter 2 inhibitor that improves glycemic control and reduces body weight and systolic blood pressure in patients with type 2 diabetes mellitus (T2DM). Dapagliflozin is effective and well tolerated over 12-24 weeks in Japanese patients with T2DM. In this study, the safety and efficacy of dapagliflozin administered as monotherapy and combination therapy were assessed over 52 weeks in Japanese patients with T2DM. METHODS This was a 52-week open-label Phase 3 study consisting of a single treatment arm with no comparator. Dapagliflozin was administered as monotherapy (n = 249) or combination therapy (n = 479) with existing antihyperglycemic agents (sulfonylurea, glinides, metformin, alpha-glucosidase inhibitors, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, or glucagon-like peptide-1 receptor agonists) to Japanese patients with T2DM and inadequate glycemic control for 52 weeks. Treatment with dapagliflozin was initiated at 5 mg/day and titrated to 10 mg/day as required. RESULTS Dapagliflozin administered as monotherapy or combination therapy was well tolerated. The frequency of adverse events (AEs) over 52 weeks was similar between monotherapy (79.1%) and combination therapy (72.4%) groups, and AEs were mostly mild or moderate. The incidence of hypoglycemia at 52 weeks was 2.4% in the monotherapy group and 4.0% in the combination therapy group. In patients receiving dapagliflozin as monotherapy or combination therapy, reductions from baseline to week 52 were observed in glycosylated hemoglobin (HbA1c) (-0.7% in both groups), weight (-2.6 and -2.1 kg, respectively), and systolic blood pressure (-5.2 mmHg and -3.9 mmHg). In patients with insufficient response to 5 mg/day, dapagliflozin was increased to 10 mg/day, and a further decrease in HbA1c from the pre-titration value was observed in both groups. CONCLUSION Dapagliflozin was well tolerated and effective as monotherapy or combination therapy in Japanese patients with T2DM over 52 weeks.
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Affiliation(s)
- Kohei Kaku
- Department of Internal Medicine, Kawasaki Medical School, Okayama, Japan,
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334
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Maranghi M, Carnovale A, Durante C, Tarquini G, Tiseo G, Filetti S. Pharmacokinetics, pharmacodynamics and clinical efficacy of dapagliflozin for the treatment of type 2 diabetes. Expert Opin Drug Metab Toxicol 2014; 11:125-37. [PMID: 25418019 DOI: 10.1517/17425255.2015.986457] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Dapagliflozin (DAPA) (Farxiga or Forxiga) is a sodium glucose cotransporter 2 (SGLT2) inhibitor approved for type 2 diabetes mellitus(T2DM) treatment. AREAS COVERED The review focuses on the pharmacokinetics (PK), pharmacodynamics(PD) and clinical studies published on DAPA. The authors searched PubMed database for English language studies describing DAPA characteristics and use in T2DM subjects published through June 2014. EXPERT OPINION DAPA exhibits favorable PK and PD properties and is effective in reducing glycemic levels. In addition, DAPA shows beneficial/neutral effects on other risk factors contributing to T2DM metabolic control. Increased risk of genital and urinary infections and episodes of volume depletion represent the major concerns for its use. FDA requires additional data to assess imbalances in bladder cancer and drug cardiovascular safety. The mechanism of action and the very low risk of drug-drug interaction make it an ideal drug for rapidly reducing glucotoxicity and restoring clinical response to other antidiabetic drugs.
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Affiliation(s)
- Marianna Maranghi
- University of Rome "Sapienza", Department of Internal Medicine and Clinical Specialities , V.le del Policlinico, 155, 00161, Rome , Italy +39 0 6 49978301 ; +39 0 6 4463783 ;
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336
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Lajara R. The potential role of sodium glucose co-transporter 2 inhibitors in combination therapy for type 2 diabetes mellitus. Expert Opin Pharmacother 2014; 15:2565-85. [PMID: 25316597 DOI: 10.1517/14656566.2014.968551] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Sodium glucose co-transporter 2 (SGLT2) inhibitors are a new class of glucose-lowering agents developed for the treatment of type 2 diabetes mellitus (T2DM). These agents have a mechanism of action that is independent of pancreatic β-cell function or the degree of insulin resistance; consequently, SGLT2 inhibitors have the potential to be used not only as monotherapy but also in combination with any of the existing classes of glucose-lowering agents, including insulin. As part of the extensive clinical development programs for modern T2DM therapies, SGLT2 inhibitors have been studied in combination with the most commonly used classes of glucose-lowering medications. AREAS COVERED This report summarizes the key clinical trials data for combination therapies using SGLT2 inhibitors currently approved in the United States and/or the European Union, namely, dapagliflozin, canagliflozin, and empagliflozin. EXPERT OPINION When given as add-on combination therapy with other glucose-lowering agents, or as monotherapy, SGLT2 inhibitors produced modest but clinically meaningful reductions in glycated hemoglobin, body weight, and systolic blood pressure. These changes have been sustained over long-term follow-up. SGLT2 inhibitors have a generally favorable safety profile similar to that of placebo, and are well tolerated. The risk of hypoglycemia appears to depend on coadministered glucose-lowering agents: when used as monotherapy, the frequency is comparable to that of placebo, but an increased risk is associated with concomitant use of sulfonylureas or insulin. In addition, an increased risk of genitourinary infections has been reported with SGLT2 inhibitors. However, these infections are usually mild, nonrecurrent, and respond to standard treatment.
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337
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Peene B, Benhalima K. Sodium glucose transporter protein 2 inhibitors: focusing on the kidney to treat type 2 diabetes. Ther Adv Endocrinol Metab 2014; 5:124-36. [PMID: 25419452 PMCID: PMC4236298 DOI: 10.1177/2042018814553965] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is increasing worldwide. Treatment of T2DM continues to present challenges, with a significant proportion of patients failing to achieve and maintain glycemic targets. Despite the availability of many oral antidiabetic agents, therapeutic efficacy is also offset by side effects such as weight gain and hypoglycemia. Therefore, the search for novel therapeutic agents with an improved benefit-risk profile continues. In the following review we focus on a novel class of oral antidiabetic drugs, the sodium glucose transporter protein 2 (SGLT2) inhibitors, which have unique characteristics. SGLT2 inhibitors focus on the kidney as a therapeutic target, where they inhibit the reabsorption of glucose in the proximal tubule, causing an increase in urinary glucose excretion. Doing this, they reduce plasma glucose independently of the β-cell function of the pancreas. SGLT2 inhibitors are effective at lowering hemoglobin A1c, but also induce weight loss and reduce blood pressure, with a low risk of hypoglycemia. In general, the SGLT2 inhibitors are well tolerated, with the most frequent adverse events being mild urinal and genital infections. Since their primary site of effect is the kidney, these drugs are less effective in patients with impaired kidney function but evidence is emerging that these drugs may also have a protective effect against diabetic nephropathy. This review focuses on the most extensively studied SGLT2 inhibitors dapagliflozin, canagliflozin and empagliflozin. Dapagliflozin and canagliflozin have already been approved for marketing by the US Food and Drug Administration. The European Medicines Agency has accepted all three drugs for marketing.
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Affiliation(s)
- Bernard Peene
- Department of Internal Medicine, UZ Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Katrien Benhalima
- Endocrinology Department, UZ Gasthuisberg, Herestraat 49, 3300 Leuven, Belgium
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Abstract
The importance of the kidney's role in glucose homeostasis has gained wider understanding in recent years. Consequently, the development of a new pharmacological class of anti-diabetes agents targeting the kidney has provided new treatment options for the management of type 2 diabetes mellitus (T2DM). Sodium glucose co-transporter type 2 (SGLT2) inhibitors, such as dapagliflozin, canagliflozin, and empagliflozin, decrease renal glucose reabsorption, which results in enhanced urinary glucose excretion and subsequent reductions in plasma glucose and glycosylated hemoglobin concentrations. Modest reductions in body weight and blood pressure have also been observed following treatment with SGLT2 inhibitors. SGLT2 inhibitors appear to be generally well tolerated, and have been used safely when given as monotherapy or in combination with other oral anti-diabetes agents and insulin. The risk of hypoglycemia is low with SGLT2 inhibitors. Typical adverse events appear to be related to the presence of glucose in the urine, namely genital mycotic infection and lower urinary tract infection, and are more often observed in women than in men. Data from long-term safety studies with SGLT2 inhibitors and from head-to-head SGLT2 inhibitor comparator studies are needed to fully determine their benefit-risk profile, and to identify any differences between individual agents. However, given current safety and efficacy data, SGLT2 inhibitors may present an attractive option for T2DM patients who are failing with metformin monotherapy, especially if weight is part of the underlying treatment consideration.
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Affiliation(s)
- Michael A Nauck
- Department of Internal Medicine, Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
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339
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Affiliation(s)
- Abd A Tahrani
- Centre of Endocrinology Diabetes and Metabolism, 2nd Floor, Institute of Biomedical Research, University of Birmingham, Birmingham B15 2TT, UK; Department of Diabetes and Endocrinology, Birmingham Heartlands Hospital, Birmingham, UK.
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340
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Ridderstråle M, Andersen KR, Zeller C, Kim G, Woerle HJ, Broedl UC. Comparison of empagliflozin and glimepiride as add-on to metformin in patients with type 2 diabetes: a 104-week randomised, active-controlled, double-blind, phase 3 trial. Lancet Diabetes Endocrinol 2014; 2:691-700. [PMID: 24948511 DOI: 10.1016/s2213-8587(14)70120-2] [Citation(s) in RCA: 267] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Metformin is the recommended first-line pharmacotherapy for patients with type 2 diabetes. There is no consensus on the optimum second-line pharmacotherapy. We compared the efficacy and safety of the sodium glucose cotransporter 2 inhibitor empagliflozin and the sulfonylurea glimepiride as add-on to metformin in patients with type 2 diabetes. METHODS In this double-blind phase 3 trial, patients (aged ≥18 years) with type 2 diabetes and HbA1c concentrations of 7-10%, despite metformin treatment and diet and exercise counselling, were randomly assigned in a 1:1 ratio with a computer-generated random sequence, stratified by HbA1c, estimated glomerular filtration rate (eGFR), and region, to empagliflozin (25 mg once daily, orally) or glimepiride (1-4 mg once daily, orally) as add-on to metformin for 104 weeks. Patients and investigators were masked to treatment assignment. The primary endpoint was change from baseline in HbA1c levels at weeks 52 and 104. Differences in the primary endpoint were first tested for non-inferiority (based on a margin of 0·3%). If non-inferiority was shown, differences in the primary endpoint at week 104 were then tested for superiority. Analysis was done on the full-analysis set-ie, patients who were treated with at least one dose of study drug and had a baseline HbA1c value. This study is registered with ClinicalTrials.gov, number NCT01167881. A 104-week extension is ongoing. FINDINGS Between August, 2010, and June, 2011, 1549 patients were randomly assigned to receive empagliflozin (n=769) or glimepiride (n=780); four patients in the empagliflozin group did not receive the assigned treatment. Empagliflozin was non-inferior to glimepiride at both timepoints. At week 104, adjusted mean difference in change from baseline in HbA1c with empagliflozin versus glimepiride was -0·11% (95% CI -0·19 to -0·02; p=0·0153 for superiority). Adverse events were reported in 661 (86%) patients treated with empagliflozin and 673 (86%) patients treated with glimepiride. Severe adverse events were reported in 72 (9%) patients in the empagliflozin group and 68 (9%) in the glimepiride group. Serious adverse events were reported in 119 (16%) patients in the empagliflozin group and 89 (11%) in the glimepiride group. Confirmed hypoglycaemic adverse events (plasma glucose ≤3·9 mmol/L or requiring assistance) at week 104 were reported in 19 (2%) patients treated with empagliflozin and 189 (24%) patients treated with glimepiride. INTERPRETATION Empagliflozin might be an effective and a well tolerated second-line treatment option for patients with type 2 diabetes who have not achieved good glycaemic control on metformin. FUNDING Boehringer Ingelheim and Eli Lilly.
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Affiliation(s)
| | | | | | - Gabriel Kim
- Boehringer Ingelheim Pharma, Ingelheim, Germany
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341
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Zinman B, Inzucchi SE, Lachin JM, Wanner C, Ferrari R, Fitchett D, Bluhmki E, Hantel S, Kempthorne-Rawson J, Newman J, Johansen OE, Woerle HJ, Broedl UC. Rationale, design, and baseline characteristics of a randomized, placebo-controlled cardiovascular outcome trial of empagliflozin (EMPA-REG OUTCOME™). Cardiovasc Diabetol 2014; 13:102. [PMID: 24943000 PMCID: PMC4072621 DOI: 10.1186/1475-2840-13-102] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/13/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Evidence concerning the importance of glucose lowering in the prevention of cardiovascular (CV) outcomes remains controversial. Given the multi-faceted pathogenesis of atherosclerosis in diabetes, it is likely that any intervention to mitigate this risk must address CV risk factors beyond glycemia alone. The SGLT-2 inhibitor empagliflozin improves glucose control, body weight and blood pressure when used as monotherapy or add-on to other antihyperglycemic agents in patients with type 2 diabetes. The aim of the ongoing EMPA-REG OUTCOME™ trial is to determine the long-term CV safety of empagliflozin, as well as investigating potential benefits on macro-/microvascular outcomes. METHODS Patients who were drug-naïve (HbA1c ≥7.0% and ≤9.0%), or on background glucose-lowering therapy (HbA1c ≥7.0% and ≤10.0%), and were at high risk of CV events, were randomized (1:1:1) and treated with empagliflozin 10 mg, empagliflozin 25 mg, or placebo (double blind, double dummy) superimposed upon the standard of care. The primary outcome is time to first occurrence of CV death, non-fatal myocardial infarction, or non-fatal stroke. CV events will be prospectively adjudicated by an independent Clinical Events Committee. The trial will continue until ≥691 confirmed primary outcome events have occurred, providing a power of 90% to yield an upper limit of the adjusted 95% CI for a hazard ratio of <1.3 with a one-sided α of 0.025, assuming equal risks between placebo and empagliflozin (both doses pooled). Hierarchical testing for superiority will follow for the primary outcome and key secondary outcomes (time to first occurrence of CV death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for unstable angina pectoris) where non-inferiority is achieved. RESULTS Between Sept 2010 and April 2013, 592 clinical sites randomized and treated 7034 patients (41% from Europe, 20% from North America, and 19% from Asia). At baseline, the mean age was 63 ± 9 years, BMI 30.6 ± 5.3 kg/m2, HbA1c 8.1 ± 0.8%, and eGFR 74 ± 21 ml/min/1.73 m2. The study is expected to report in 2015. DISCUSSION EMPA-REG OUTCOME™ will determine the CV safety of empagliflozin in a cohort of patients with type 2 diabetes and high CV risk, with the potential to show cardioprotection. TRIAL REGISTRATION Clinicaltrials.gov NCT01131676.
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Affiliation(s)
- Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
- Division of Endocrinology, University of Toronto, Toronto, Canada
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - John M Lachin
- The Biostatistics Center, The George Washington University, Rockville, MD, USA
| | - Christoph Wanner
- Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg, Germany
| | - Roberto Ferrari
- Section of Cardiology, University of Ferrara, Ferrara, Italy
| | - David Fitchett
- St Michael’s Hospital, Toronto, Canada
- Division of Cardiology, University of Toronto, Toronto, Canada
| | - Erich Bluhmki
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Stefan Hantel
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | - Jennifer Newman
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
| | | | | | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
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342
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Sun YN, Zhou Y, Chen X, Che WS, Leung SW. The efficacy of dapagliflozin combined with hypoglycaemic drugs in treating type 2 diabetes mellitus: meta-analysis of randomised controlled trials. BMJ Open 2014; 4:e004619. [PMID: 24710132 PMCID: PMC3987716 DOI: 10.1136/bmjopen-2013-004619] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES This meta-analysis aimed to evaluate whether dapagliflozin is synergistic with other antidiabetic drugs without body weight gain. SETTING Randomised controlled trial (RCT) reports were retrieved from PubMed, Cochrane Library, EMBASE, ClinicalTrials.gov, Google Scholar and Google. Eligible RCTs were selected according to the criteria (including types of participants, intervention, outcomes) and assessed by the Cochrane risk of bias tool and GRADEpro software for evidential quality. Meta-analysis on the eligible RCTs was performed with the random effects model. The RCTs of low-quality and interim stages were excluded for further sensitivity analysis. Meta-regression was conducted on the follow-up durations. Publication bias was evaluated with funnel plots and the Egger's regression test and adjusted using the trim-and-fill procedure. Heterogeneity was assessed with the I(2) statistics. PARTICIPANTS Adult patients with type 2 diabetes mellitus (T2DM). INTERVENTIONS Dapagliflozin combined with conventional antidiabetic drugs. PRIMARY AND SECONDARY OUTCOME MEASURES Glycaemic level (measured by glycosylated haemoglobin (HbA1c) and fasting plasma glucose (FPG)) and body weight. RESULTS 12 RCTs were eligible for quantitative synthesis and meta-analysis. The overall effect size of HbA1c calculated from mean difference was -0.52% (Z=-13.56, p<0.001) with 95% CI (-0.60 to -0.45). The effect size of FPG was -1.13 mmol/L (Z=-11.12, p<0.001) with 95% CI (-1.33 to -0.93). The effect size of body weight was -2.10 kg (Z=-18.77, p<0.001) with 95% CI (-2.32 to -1.88). Exclusions of low quality and interim RCTs changed the overall mean differences respectively to -0.56%, -1.11 mmol/L, 2.23 kg and -0.50%, -1.08 mmol/L, -2.08 kg. The sensitivity analysis indicated good robustness of the meta-analysis on HbA1c, FPG and body weight. CONCLUSIONS The meta-analysis showed that dapagliflozin as an add-on drug to conventional antidiabetic drugs improved the glycaemic control in T2DM participants without significant body weight gain. TRIAL REGISTRATION NUMBER CRD42013005034.
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Affiliation(s)
- Yu-nan Sun
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China
| | - Yi Zhou
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China
| | - Xi Chen
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China
| | - Weng-si Che
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China
| | - Siu-wai Leung
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao, China
- School of Informatics, University of Edinburgh, Edinburgh, Scotland, UK
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343
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Ferrannini E, Muscelli E, Frascerra S, Baldi S, Mari A, Heise T, Broedl UC, Woerle HJ. Metabolic response to sodium-glucose cotransporter 2 inhibition in type 2 diabetic patients. J Clin Invest 2014; 124:499-508. [PMID: 24463454 DOI: 10.1172/jci72227] [Citation(s) in RCA: 831] [Impact Index Per Article: 83.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 11/14/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 (SGLT2) inhibitors lower glycemia by enhancing urinary glucose excretion. The physiologic response to pharmacologically induced acute or chronic glycosuria has not been investigated in human diabetes. METHODS We evaluated 66 patients with type 2 diabetes (62 ± 7 years, BMI = 31.6 ± 4.6 kg/m(2), HbA1c = 55 ± 8 mmol/mol, mean ± SD) at baseline, after a single dose, and following 4-week treatment with empagliflozin (25 mg). At each time point, patients received a mixed meal coupled with dual-tracer glucose administration and indirect calorimetry. RESULTS Both single-dose and chronic empagliflozin treatment caused glycosuria during fasting (median, 7.8 [interquartile range {IQR}, 4.4] g/3 hours and 9.2 [IQR, 5.2] g/3 hours) and after meal ingestion (median, 29.0 [IQR, 12.5] g/5 hours and 28.2 [IQR, 15.4] g/5 hours). After 3 hours of fasting, endogenous glucose production (EGP) was increased 25%, while glycemia was 0.9 ± 0.7 mmol/l lower (P < 0.0001 vs. baseline). After meal ingestion, glucose and insulin AUC decreased, whereas the glucagon response increased (all P < 0.001). While oral glucose appearance was unchanged, EGP was increased (median, 40 [IQR, 14] g and 37 [IQR, 11] g vs. 34 [IQR, 11] g, both P < 0.01). Tissue glucose disposal was reduced (median, 75 [IQR, 16] g and 70 [IQR, 21] g vs. 93 [IQR, 18] g, P < 0.0001), due to a decrease in both glucose oxidation and nonoxidative glucose disposal, with a concomitant rise in lipid oxidation after chronic administration (all P < 0.01). β Cell glucose sensitivity increased (median, 55 [IQR, 35] pmol • min(-1) • m(-2) • mM(-1) and 55 [IQR, 39] pmol • min(-1) • m(-2) • mM(-1) vs. 44 [IQR, 32] pmol • min(-1) • m(-2) • mM(-1), P < 0.0001), and insulin sensitivity was improved. Resting energy expenditure rates and those after meal ingestion were unchanged. CONCLUSIONS In patients with type 2 diabetes, empagliflozin-induced glycosuria improved β cell function and insulin sensitivity, despite the fall in insulin secretion and tissue glucose disposal and the rise in EGP after one dose, thereby lowering fasting and postprandial glycemia. Chronic dosing shifted substrate utilization from carbohydrate to lipid. Trial registration. ClinicalTrials.Gov NCT01248364 (EudraCT no. 2010-018708-99). Funding. This study was funded by Boehringer Ingelheim.
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Napoli N, Strollo R, Paladini A, Briganti SI, Pozzilli P, Epstein S. The alliance of mesenchymal stem cells, bone, and diabetes. Int J Endocrinol 2014; 2014:690783. [PMID: 25140176 PMCID: PMC4124651 DOI: 10.1155/2014/690783] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 06/11/2014] [Indexed: 12/15/2022] Open
Abstract
Bone fragility has emerged as a new complication of diabetes. Several mechanisms in diabetes may influence bone homeostasis by impairing the action between osteoblasts, osteoclasts, and osteocytes and/or changing the structural properties of the bone tissue. Some of these mechanisms can potentially alter the fate of mesenchymal stem cells, the initial precursor of the osteoblast. In this review, we describe the main factors that impair bone health in diabetic patients and their clinical impact.
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Affiliation(s)
- Nicola Napoli
- Division of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
- Division of Bone and Mineral Diseases, Washington University in St Louis, St Louis, MO, USA
- *Nicola Napoli:
| | - Rocky Strollo
- Division of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Angela Paladini
- Division of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Silvia I. Briganti
- Division of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
| | - Paolo Pozzilli
- Division of Endocrinology and Diabetes, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
- Centre for Diabetes, The Blizard Building, Barts and The London School of Medicine, Queen Mary, University of London, London, UK
| | - Sol Epstein
- Division of Endocrinology, Mount Sinai School of Medicine, New York, USA
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