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Mondal S, Pramanik S, Khare VR, Fernandez CJ, Pappachan JM. Sodium glucose cotransporter-2 inhibitors and heart disease: Current perspectives. World J Cardiol 2024; 16:240-259. [PMID: 38817648 PMCID: PMC11135334 DOI: 10.4330/wjc.v16.i5.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 04/08/2024] [Accepted: 04/28/2024] [Indexed: 05/23/2024] Open
Abstract
Sodium glucose cotransporter-2 inhibitors (SGLT-2i) are antidiabetic medications with remarkable cardiovascular (CV) benefits proven by multiple randomised controlled trials and real-world data. These drugs are also useful in the prevention of CV disease (CVD) in patients with diabetes mellitus (DM). Although DM as such is a huge risk factor for CVD, the CV benefits of SGLT-2i are not just because of antidiabetic effects. These molecules have proven beneficial roles in prevention and management of nondiabetic CVD and renal disease as well. There are various molecular mechanisms for the organ protective effects of SGLT-2i which are still being elucidated. Proper understanding of the role of SGLT-2i in prevention and management of CVD is important not only for the cardiologists but also for other specialists caring for various illnesses which can directly or indirectly impact care of heart diseases. This clinical review compiles the current evidence on the rational use of SGLT-2i in clinical practice.
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Affiliation(s)
- Sunetra Mondal
- Department of Endocrinology, NRS Medical College, Kolkata 700020, West Bengal, India
| | - Subhodip Pramanik
- Department of Endocrinology, Neotia Getwel Multispecialty Hospitals, Siliguri 734010, West Bengal, India
| | - Vibhu Ranjan Khare
- Department of Endocrinology, NRS Medical College, Kolkata 700020, West Bengal, India
| | - Cornelius James Fernandez
- Department of Endocrinology and Metabolism, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston PE21 9QS, United Kingdom
| | - Joseph M Pappachan
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
- Faculty of Science, Manchester Metropolitan University, Manchester M15 6BH, United Kingdom
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PL, United Kingdom.
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Huang Y, Zhou H, Fang C, Ma L, Zhang Y, Rong W, Liu X, Ye H. Cost-Effectiveness of New Quadruple Therapy Compared With Standard Treatment for Patients With Heart Failure in China. J Cardiovasc Pharmacol 2024; 83:86-92. [PMID: 38180456 DOI: 10.1097/fjc.0000000000001476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/18/2023] [Indexed: 01/06/2024]
Abstract
ABSTRACT This study aimed to compare the cost-effectiveness of the new quadruple therapy regimen of adding sodium-glucose-linked transporter 2 (SGLT2) inhibitors, with standard treatment for patients with heart failure (HF) in China. From the payer's perspective, the dates of cardiovascular event recurrences were extracted from a meta-analysis including 6 trials, combined with the treatment cost for patients with HF in China to construct a Markov model. The outcomes included per capita medical costs and incremental cost-effectiveness ratio, using quality-adjusted life years (QALYs) data. Single-factor, probability sensitivity analysis, and scenario analysis were used to explore the potential uncertainties of the model. The per capita costs of the new quadruple therapy regimen and standard treatment were $87441.26 and $87087.54, respectively. The new regimen was associated with a mean of 21.44 QALYs gained, compared with 18.60 QALYs gained with the standard treatment. The incremental cost-effectiveness ratio was $124.03 per QALY gained. The sensitivity analysis revealed that changes in the parameters within the set range did not affect the model results. In China, compared with standard treatment, the new quadruple therapy regimen with SGLT2 inhibitors reduce the frequency of cardiovascular events among patients with HF, and it has economic advantages.
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Affiliation(s)
- Yun Huang
- Department of Pharmacy, Ningbo Medical Center, Li Huili Hospital, Ningbo University, Ningbo, Zhijiang, China
| | - Hua Zhou
- Department of Pharmacy, Ningbo Medical Center, Li Huili Hospital, Ningbo University, Ningbo, Zhijiang, China
| | - Chongbo Fang
- Department of Pharmacy, Ningbo Medical Center, Li Huili Hospital, Ningbo University, Ningbo, Zhijiang, China
| | - Lili Ma
- Department of Pharmacy, Ningbo Medical Center, Li Huili Hospital, Ningbo University, Ningbo, Zhijiang, China
| | - Yuyu Zhang
- Department of Pharmacy, Ningbo Medical Center, Li Huili Hospital, Ningbo University, Ningbo, Zhijiang, China
| | - Weibo Rong
- Department of Pharmacy, Ningbo Medical Center, Li Huili Hospital, Ningbo University, Ningbo, Zhijiang, China
| | - Xiaoli Liu
- The Second Affiliated Hospital of Hunan University of Traditional Chinese Medicine, Changsha, Hunan, China; and
| | - Honghua Ye
- Department of Cardiology, Ningbo Medical Center, Li Huili Hospital, Ningbo University, Ningbo, Zhijiang, China
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Kongmalai T, Hadnorntun P, Leelahavarong P, Kongmalai P, Srinonprasert V, Chirakarnjanakorn S, Chaikledkaew U, McKay G, Attia J, Thakkinstian A. Comparative cardiovascular benefits of individual SGLT2 inhibitors in type 2 diabetes and heart failure: a systematic review and network meta-analysis of randomized controlled trials. Front Endocrinol (Lausanne) 2023; 14:1216160. [PMID: 38179304 PMCID: PMC10765518 DOI: 10.3389/fendo.2023.1216160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 11/17/2023] [Indexed: 01/06/2024] Open
Abstract
Background In patients with type 2 diabetes (T2D) and a history of heart failure (HF), sodium-glucose cotransporter-2 inhibitors (SGLT2is) have demonstrated cardiovascular (CV) benefits. However, the comparative efficacy of individual SGLT2is remains uncertain. This network meta-analysis (NMA) compared the efficacy and safety of five SGLT2is (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, and sotagliflozin) on CV outcomes in these patients. Materials and methods PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched up to September 23, 2022, to identify all randomized controlled trials (RCTs) comparing SGLT2is to placebo in T2D patients with HF. The main outcomes included composite CV death/heart failure hospitalization (HFH), HFH, CV death, all-cause mortality, and adverse events. Pairwise and NMA approaches were applied. Results Our analysis included 11 RCTs with a total of 20,438 patients with T2D and HF. All SGLT2is significantly reduced HFH compared to standard of care (SoC) alone. "Add-on" SGLT2is, except ertugliflozin, significantly reduced composite CV death/HFH relative to SoC alone. Moreover, canagliflozin had lower composite CV death/HFH compared to dapagliflozin. Based on the surface under the cumulative ranking curve (SUCRA), the top-ranked SGLT2is for reducing HFH were canagliflozin (95.5%), sotagliflozin (66.0%), and empagliflozin (57.2%). Head-to-head comparisons found no significant differences between individual SGLT2is in reducing CV death. "Add-on" SGLT2is reduced all-cause mortality compared with SoC alone, although only dapagliflozin was statistically significant. No SGLT2is were significantly associated with serious adverse events. A sensitivity analysis focusing on HF-specific trials found that dapagliflozin, empagliflozin, and sotagliflozin significantly reduced composite CV death/HFH, consistent with the main analysis. However, no significant differences were identified from their head-to-head comparisons in the NMA. The SUCRA indicated that sotagliflozin had the highest probability of reducing composite CV death/HFH (97.6%), followed by empagliflozin (58.4%) and dapagliflozin (44.0%). Conclusion SGLT2is significantly reduce the composite CV death/HFH outcome. Among them, canagliflozin may be considered the preferred treatment for patients with diabetes and a history of heart failure, but it may also be associated with an increased risk of any adverse events compared to other SGLT2is. However, a sensitivity analysis focusing on HF-specific trials identified sotagliflozin as the most likely agent to reduce CV death/HFH, followed by empagliflozin and dapagliflozin. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022353754.
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Affiliation(s)
- Tanawan Kongmalai
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Siriraj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phorntida Hadnorntun
- Siriraj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pattara Leelahavarong
- Siriraj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pinkawas Kongmalai
- Department of Orthopedics, Faculty of Medicine, Kasetsart University, Bangkok, Thailand
| | - Varalak Srinonprasert
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Siriraj Health Policy Unit, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Srisakul Chirakarnjanakorn
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Usa Chaikledkaew
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Gareth McKay
- Centre for Public Health, School of Medicine, Dentistry, and Biomedical Sciences, Queen’s University, Belfast, United Kingdom
| | - John Attia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
| | - Ammarin Thakkinstian
- Mahidol University Health Technology Assessment (MUHTA) Graduate Program, Mahidol University, Bangkok, Thailand
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Lam-Chung CE. Comprehensive review of SGLT2 inhibitors' efficacy through their diuretic mode of action in diabetic patients. Front Endocrinol (Lausanne) 2023; 14:1174692. [PMID: 37547306 PMCID: PMC10400285 DOI: 10.3389/fendo.2023.1174692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/08/2023] [Indexed: 08/08/2023] Open
Abstract
SGLT2 inhibitors (SGLT2i) are now the mainstay therapy for both diabetes and heart failure. Post-hoc publications, meta-analysis, and conference presentations of the eight SGLT2i Cardiovascular Outcomes trials (CVOTS) done in diabetic patients constantly echo that this class of drug decreases mortality, reduces cardiovascular events, and prevents heart failure and kidney disease. This review of medical agencies' SGLT2i analysis (FDA and EMA) helps to understand the reality of SGLT2i results in those trials, avoiding to consider observational and statistically undemonstrated endpoints as validated. They also confirmed the unique diuretic mode of action of SGLT2i, promoting osmotic diuresis, and its potential adverse events secondary to hypovolemia and hematocrit increase. They also support the understanding that the beliefs in SGLT2i morbi-mortality benefits are largely overstated mostly based on undemonstrated endpoints. Finally, it is clear that SGLT2i's antidiabetic action, secondary to its renal mode of action, plateaued after a few months and decreased strongly over time, questioning its long-term goal of maintaining diabetic patients' HbA1c below 7%. Also, this effect in patients with renal impairment is quasi null. We think that this review would be very helpful to every physician treating diabetic patients to better balance belief and reality of SGLT2i prescription effects.
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Affiliation(s)
- Cesar Ernesto Lam-Chung
- Department of Endocrinology and Metabolism, Complejo Hospitalario Dr. Manuel Amador Guerrero, Colón, Panama
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Desai RJ, Glynn RJ, Everett BM, Schneeweiss S, Wexler DJ, Bessette LG, Déruaz-Luyet A, Vedin O, Brodovicz K, Patorno E. Comparative effectiveness of Empagliflozin in reducing the burden of recurrent cardiovascular hospitalizations among older adults with diabetes in routine clinical care. Am Heart J 2022; 254:203-215. [PMID: 36150454 DOI: 10.1016/j.ahj.2022.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 07/21/2022] [Accepted: 09/19/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The effect of sodium glucose cotransporter 2 inhibitors (SGLT2i) on the total (first and recurrent) burden of cardiovascular (CV) hospitalizations, including hospitalization for heart failure, myocardial infarction, and stroke, is poorly understood. OBJECTIVE To assess the effect of empagliflozin, an SGLT2i, on total CV hospitalizations among older adults with T2D. METHODS Using data from Medicare fee-for-service (08/2014-09/2017), we identified 1:1 propensity score-matched cohorts of patients with T2D initiating empagliflozin versus sitagliptin or empagliflozin versus glucagon-like peptide-1 receptor agonists (GLP-1RA), balancing >140 baseline covariates. We compared the risk of first and recurrent hospitalizations with any CV condition as the primary discharge diagnosis (ICD-9: 390-459; ICD-10: I00-I99), hospitalizations for heart failure (HHF), and myocardial infarctions (MI) or stroke. We estimated treatment effects based on the Ghosh-Lin semiparametric model for recurrent events as primary and joint frailty model as secondary analysis. RESULTS We included 11,429 matched-pairs of empagliflozin and sitagliptin initiators and 17,502 matched-pairs of empagliflozin and GLP1-RA initiators with an average age of 72 years. Empagliflozin was associated with a reduced risk of total CV hospitalizations (0.80 [0.69-0.93] vs sitagliptin; 0.88 [0.77-1.00] vs GLP-1RA) and total HHF (0.70 [0.51-0.98] vs sitagliptin; 0.76 [0.56-1.03] vs GLP1-RA) over a mean follow up of 6.3 months. No differences between treatments were observed for MI or stroke. Results were consistent for joint frailty models. CONCLUSION Empagliflozin, compared to sitagliptin or to a lesser extent GLP1-RA, was associated with a reduction in the burden of total CV hospitalizations and HHF in older patients with T2D.
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Affiliation(s)
- Rishi J Desai
- Division of Pharmacoepidemiology, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.
| | - Robert J Glynn
- Division of Pharmacoepidemiology, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Brendan M Everett
- Divisions of Cardiovascular and Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Deborah J Wexler
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, MA
| | - Lily G Bessette
- Division of Pharmacoepidemiology, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Anouk Déruaz-Luyet
- Boehringer Ingelheim, Ingelheim (Germany), Stockholm, (Sweden), and Ridgefield, CT
| | - Ola Vedin
- Boehringer Ingelheim, Ingelheim (Germany), Stockholm, (Sweden), and Ridgefield, CT
| | - Kimberly Brodovicz
- Boehringer Ingelheim, Ingelheim (Germany), Stockholm, (Sweden), and Ridgefield, CT
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
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Scheen AJ. Counteracting heart failure with diabetes drugs: a review into the pharmacokinetic and pharmacodynamic properties. Expert Opin Drug Metab Toxicol 2022; 18:381-393. [PMID: 35876091 DOI: 10.1080/17425255.2022.2105693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION : Heart failure (HF) is becoming a huge public health burden. New diabetes drugs for type 2 diabetes (T2D), sodium-glucose cotransporter type 2 inhibitors (SGLT2is), reduce the rate of hospitalization for HF in placebo-controlled trials. AREAS COVERED : Pharmacokinetics of dapagliflozin and empagliflozin (in presence of renal impairment and hepatic dysfunction, two comorbidities frequently associated with HF) and pharmacodynamic studies in patients with HF. Main HF outcomes in T2D patients with cardiovascular risk and in patients with reduced (HFrEF) or preserved (HFpEF) ejection fraction, with or without T2D, from DAPA-HF, EMPEROR-Reduced and EMPEROR-Preserved original findings and post hoc analyses. EXPERT OPINION : No clinically relevant changes are expected concerning SGLT2i pharmacokinetics in patients with HF while pharmacodynamic studies reported improvements in myocardium/vascular parameters, biomarkers and functional status. All SGLT2is showed a remarkable reduction in hospitalization for HF in patients with T2D and high cardiovascular risk. Furthermore, both dapagliflozin and empagliflozin improved the prognosis of patients with HFrEF, independently of the presence of T2D. Similar results were reported with empagliflozin in patients with HFpEF, to be confirmed with dapagliflozin in an ongoing trial (DELIVER). Thus, SGLT2is offer a new opportunity for the prevention and management of HF in patients with or without T2D.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.,Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium
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Shi Z, Gao F, Liu W, He X. Comparative Efficacy of Dapagliflozin and Empagliflozin of a Fixed Dose in Heart Failure: A Network Meta-Analysis. Front Cardiovasc Med 2022; 9:869272. [PMID: 35445086 PMCID: PMC9013819 DOI: 10.3389/fcvm.2022.869272] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/09/2022] [Indexed: 12/22/2022] Open
Abstract
Background The efficacy of dapagliflozin and empagliflozin in sodium-glucose cotransport-2 inhibitors (SGLT-2i) in patients with heart failure (HF) has been discovered. However, which drug could improve varied prognostic outcomes has not been elucidated. Hence, we compared their efficacies on the prognostic improvement of HF. Methods Databases including PubMed, EMBASE, Scopus, Google Scholars, and the Cochrane Library were searched for all related randomized controlled trials (RCTs) published from inception to 13 October 2021. Network meta-analyses were performed to generate matrices to show the effect size for pairwise comparison regarding all the interventions. Results Eventually a total of 11 RCTs were included in this study. For the primary endpoints, dapagliflozin was comparable with empagliflozin in hospitalization for HF, and empagliflozin (OR=0.70, 95%CI: 0.59–0.84) decreased the risk of exacerbation of HF over dapagliflozin. For the secondary endpoints, dapagliflozin was comparable with empagliflozin in cardiovascular (CV) death /hospitalization for HF, and for CV death, dapagliflozin (OR=0.78, 95%CI: 0.65–0.92) significantly reduced mortality over the placebo. For the tertiary endpoints, dapagliflozin (OR=0.80, 95%CI: 0.66–0.98) significantly decreased the mortality over empagliflozin in all-cause death, and neither drug significantly increased the risk of hypoglycemia. Recommendations Overall, 10 mg/day dapagliflozin may be the optimal recommendation for its premium and comprehensive effect on improving the prognosis of patients with HF compared to 10 mg/day empagliflozin.
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Patorno E, Pawar A, Wexler DJ, Glynn RJ, Bessette LG, Paik JM, Najafzadeh M, Brodovicz KG, Déruaz-Luyet A, Schneeweiss S. Effectiveness and safety of empagliflozin in routine care patients: Results from the EMPagliflozin compaRative effectIveness and SafEty (EMPRISE) study. Diabetes Obes Metab 2022; 24:442-454. [PMID: 34729891 PMCID: PMC8939295 DOI: 10.1111/dom.14593] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/20/2021] [Accepted: 10/31/2021] [Indexed: 01/10/2023]
Abstract
AIM To investigate effectiveness and safety outcomes among patients with type 2 diabetes (T2D) initiating empagliflozin versus dipeptidyl peptidase-4 (DPP-4) inhibitor treatment across the broad spectrum of cardiovascular risk. METHODS In a population-based cohort study we identified 39 072 pairs of 1:1 propensity score-matched adult patients with T2D initiating empagliflozin or DPP-4 inhibitors, using data from 2 US commercial insurance databases and Medicare between August 2014 and September 2017. The primary outcomes were a composite of myocardial infarction (MI)/stroke, and hospitalization for heart failure (HHF). Safety outcomes were bone fractures, lower-limb amputations (LLAs), diabetic ketoacidosis (DKA), and acute kidney injury (AKI). We estimated pooled hazard ratios (HRs) and 95% confidence intervals (CIs) adjusting for more than 140 baseline covariates. RESULTS Study participants had a mean age of 60 years and only 28% had established cardiovascular disease. Compared to DPP-4 inhibitors, empagliflozin was associated with similar risk of MI/stroke (HR 0.99 [95% CI 0.81-1.21]), and lower risk of HHF (HR 0.48 [95% CI 0.35-0.67] and 0.63 [95% CI 0.54-0.74], based on a primary and any heart failure discharge diagnosis, respectively). The HR was 0.52 (95% CI 0.38-0.72) for all-cause mortality (ACM) and 0.83 (95% CI 0.70-0.98) for a composite of MI/stroke/ACM. Empagliflozin was associated with a similar risk of LLA and fractures, an increased risk of DKA (HR 1.71 [95% CI 1.08-2.71]) and a decreased risk of AKI (HR 0.60 [95% CI 0.43-0.85]). CONCLUSIONS In clinical practice, the initiation of empagliflozin versus a DPP-4 inhibitor was associated with a lower risk of HHF, ACM and MI/stroke/ACM, a similar risk of MI/stroke, and a safety profile consistent with documented information.
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Affiliation(s)
- Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah J Wexler
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lily G Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Julie M Paik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mehdi Najafzadeh
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberly G Brodovicz
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, USA
| | | | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Matsuba I, Takihata M, Takai M, Maeda H, Kubota A, Iemitsu K, Umezawa S, Obana M, Kaneshiro M, Kawata T, Takuma T, Takeda H, Machimura H, Mokubo A, Motomiya T, Asakura T, Kikuchi T, Matsuzawa Y, Ito S, Miyakawa M, Terauchi Y, Kanamori A. Effects of 1-year treatment with canagliflozin on body composition and total body water in patients with type 2 diabetes. Diabetes Obes Metab 2021; 23:2614-2622. [PMID: 34338409 DOI: 10.1111/dom.14508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/22/2021] [Accepted: 07/28/2021] [Indexed: 01/14/2023]
Abstract
AIM To characterize the long-term changes in body composition associated with sodium-glucose cotransporter-2 (SGLT2) inhibitors. MATERIALS AND METHODS In this multicentre, single-arm, open-label study, 107 patients with type 2 diabetes were treated with canagliflozin 100 mg, as add-on therapy, for 12 months. Body composition was measured with a body composition analyser (T-SCAN PLUS) using the impedance method to prospectively analyse changes in body components, including percentage of body fat, body fat mass, total body water, muscle mass and mineral mass. Estimated plasma volume (PV) was calculated using the Kaplan formula. RESULTS Body weight showed a significant decrease from 1 month to 12 months of treatment with canagliflozin, with a higher rate of decrease in body fat in body composition. A significant decrease in mineral mass was also observed, but its rate was low. Following treatment with canagliflozin, changes in total body water did not affect intracellular water, and a significant decrease in extracellular water, including plasma components, was observed early and was sustained up to 12 months. Protein mass, a component of muscle mass, was not affected, with only a slight decrease in water volume observed. CONCLUSIONS Canagliflozin decreased extracellular fluid and PV in addition to decreasing fat in the body via calorie loss resulting from urinary glucose excretion. This study suggested that SGLT2 inhibitors might reduce body weight by regulating fat mass or water distribution in the body and might have cardiac and renal protective effects by resetting the homeostasis of fluid balance.
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Affiliation(s)
- Ikuro Matsuba
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Masahiro Takihata
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Masahiko Takai
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Hajime Maeda
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Akira Kubota
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Kotaro Iemitsu
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Shinichi Umezawa
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Mitsuo Obana
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Mizuki Kaneshiro
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Takehiro Kawata
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Tetsuo Takuma
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Hiroshi Takeda
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Hideo Machimura
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Atsuko Mokubo
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Tetsuya Motomiya
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Taro Asakura
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Taisuke Kikuchi
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Yoko Matsuzawa
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Shogo Ito
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Masaaki Miyakawa
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
| | - Yasuo Terauchi
- Department of Endocrinology and Metabolism, Yokohama City University, Yokohama, Japan
| | - Akira Kanamori
- The Study Group of the Diabetes Committee, Kanagawa Physicians Association, Yokohama, Japan
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10
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Janež A, Fioretto P. SGLT2 Inhibitors and the Clinical Implications of Associated Weight Loss in Type 2 Diabetes: A Narrative Review. Diabetes Ther 2021; 12:2249-2261. [PMID: 34244976 PMCID: PMC8342745 DOI: 10.1007/s13300-021-01104-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/03/2021] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION The obesity epidemic is closely linked to the rising prevalence of type 2 diabetes (T2D). Body weight reduction remains an important challenge in patients with T2D, as it requires changing their overall metabolic control. Of all glucose-lowering therapies, only sodium-glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide 1 receptor agonists (GLP-1 RAs) consistently result in weight improvement. Moreover, the same two classes have important cardiovascular and renal benefits. We summarize the key available information related to the weight loss effect of SGLT2is in T2D, focusing on the unexploited potential of these drugs. METHODS Data on weight change with SGLT2is in patients with T2D were extracted from published cardiovascular outcomes trials (CVOTs). A discussion on patient perspectives about weight change is based on key preclinical and clinical trials, meta-analyses, and reviews and is supplemented by the authors' clinical judgment and research experience in the field. RESULTS SGLT2is have a unique mode of action resulting in caloric loss through glycosuria. The anticipated weight loss with SGLT2is is not reflected in clinical trial results. There is a discrepancy between the magnitude of improvement in glycemic control and the weight loss, cardiovascular, and renal benefits obtained in large clinical trials. CONCLUSION The relationships between the magnitude of weight loss, improvement in glycemic control, and cardiorenal benefits with SGLT2i are still unclear. Potential mechanisms other than simple glycemic efficacy should be revealed and explained. Better weight control may be achieved if adequately intensive lifestyle changes are implemented and monitored in the T2D population treated with SGLT2is.
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Affiliation(s)
- Andrej Janež
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000, Ljubljana, Slovenia.
| | - Paola Fioretto
- Department of Medicine, University of Padua, Padua, Italy
- Unit of Medical Clinic 3, Hospital of Padua, Padua, Italy
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11
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Pan D, Xu L, Chen P, Jiang H, Shi D, Guo M. Empagliflozin in Patients With Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Cardiovasc Med 2021; 8:683281. [PMID: 34239906 PMCID: PMC8257947 DOI: 10.3389/fcvm.2021.683281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 04/30/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose: The purpose of the study is to evaluate the effect of empagliflozin in patients with heart failure (HF). Method: We performed a systematic search of PubMed, EMBASE, and the Cochrane Library database through January 20, 2021. Randomized controlled trials (RCTs) were included that compared empagliflozin and placebo in patients with HF. Dichotomous variables were expressed as risk ratios (RRs) with 95% confidence intervals (CIs). Continuous variables were calculated and expressed as mean differences (MD) and standard deviation (SD). Meta-analysis was conducted using a random-effects model on outcomes with high heterogeneity. Results: Seven studies were included in our meta-analysis (n = 5,150). Significant differences were observed in a composite of cardiovascular death or hospitalization for worsening heart failure [RR: 0.77 (95% CI 0.68-0.87); I 2 = 18%; P < 0.0001), hospitalization for worsening heart failure [RR: 0.71 (95% CI 0.61-0.82); I 2 = 0%; P < 0.00001], changes in Kansas City Cardiomyopathy Questionnaire (KCCQ) score [MD: 1.70 (95% CI 1.67-1.73); I 2 = 0%; P < 0.00001], and changes in body weight [MD: -1.43 (95% CI -2.15 to -0.72); I 2 = 84%; P < 0.0001) from baseline. However, empagliflozin did not show a better change in the 6-min walk test (6MWT) [MD: 34.06 (95% CI -29.75-97.88); I 2 = 97%; P = 0.30] or NT-proBNP [MD: -98.36 (95% CI, -225.83-29.11); I 2 = 68%; P = 0.13] from baseline. Conclusion: The findings suggest that empagliflozin was effective in reducing a composite of cardiovascular death or hospitalization for worsening heart failure. Further well-designed RCTs are needed to evaluate the long-term effect of empagliflozin in patients with HF. PROSPERO: CRD42021231712.
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Affiliation(s)
- Deng Pan
- Graduate School of Beijing University of Traditional Chinese Medicine, Beijing, China.,National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Lin Xu
- Gynecological Department of Traditional Chinese Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Pengfei Chen
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.,Graduate School of China Academy of Chinese Medical Sciences, Beijing, China
| | | | - Dazhuo Shi
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ming Guo
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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12
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Cavka L, Bencak Ferko U, Pitz N, Trpkovski Z, Lainscak M. Sodium-glucose cotransporter 2 inhibitor-induced euglycaemic diabetic ketoacidosis in heart failure with preserved ejection fraction. ESC Heart Fail 2021; 8:2631-2636. [PMID: 34102028 PMCID: PMC8318418 DOI: 10.1002/ehf2.13452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/17/2021] [Accepted: 05/21/2021] [Indexed: 12/13/2022] Open
Abstract
The number of patients receiving sodium-glucose cotransporter 2 inhibitors (SGLT2is), especially those with heart failure, is increasing worldwide. SGLT2is control glycaemia by triggering glycosuria with simultaneous facilitation of a more ketogenic metabolic profile. Patients therefore are more prone to develop euglycaemic diabetic ketoacidosis (euDKA), an entity largely unknown beyond diabetes care professionals. We present a heart failure with preserved ejection fraction (HFpEF) patient with known Type 2 diabetes. He was treated with dapagliflozin and presented acutely with dyspnoea, hyperglycaemia, and ketoacidosis. After standard treatment for diabetic ketoacidosis, hyperglycaemia was corrected, while metabolic ketoacidosis persisted, and thus, euDKA was suspected. With adequate therapy, the patient recovered completely and was discharged without any sequelae. To the best of our knowledge, our case is the first to describe SGLT2i-induced euDKA in HFpEF patients. Regarding no previous reports of euDKA in heart failure with reduced ejection fraction, our report is highly relevant for ongoing SGLT2i trials in HFpEF and clinical practice in general.
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Affiliation(s)
- Luka Cavka
- Division of Medical Oncology, Institute of Oncology Ljubljana, Zaloška cesta 2, Ljubljana, 1000, Slovenia.,Department of Oncology, University Medical Center Maribor, Maribor, Slovenia.,Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia
| | - Urska Bencak Ferko
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia
| | - Natasa Pitz
- Division for Diabetes, General Hospital Murska Sobota, Murska Sobota, Slovenia
| | - Zoranco Trpkovski
- Division for Diabetes, General Hospital Murska Sobota, Murska Sobota, Slovenia
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Faculty of Natural Sciences and Mathematics, University of Maribor, Maribor, Slovenia
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13
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Abstract
In recent decades, considerable advances have been made in the treatment of heart failure. The main target of heart failure therapy is the inhibition of the sympathetic nervous system and renin-angiotensin-aldosterone system. The angiotensin receptor blockers represent a breakthrough in the treatment of heart failure with a demonstrated effect on reduction of cardiovascular events. However, new perspectives derive from latest drugs developed for diabetes, iron deficiency, and hyperkalemia. New frontiers are also opened to the development of neurohormonal therapies, antagonists of inflammatory mediators, inotropic agents, and cell-based treatments.
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14
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Oh J, Lee SH, Lee CJ, Kang SM. Sodium-glucose Co-transporter 2 Inhibitors: a New Path for Heart Failure Treatment. Korean Circ J 2021; 51:399-408. [PMID: 33975387 PMCID: PMC8112180 DOI: 10.4070/kcj.2021.0070] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/10/2021] [Indexed: 01/05/2023] Open
Abstract
Sodium-glucose co-transporter 2 inhibitors (SGLT2i) have been emerged as a powerful
therapeutic option to reduce the risk of heart failure and hospitalization for heart
failure (HFH) in patients with type II diabetes mellitus (T2DM), and to reduce
cardiovascular mortality and HFH in heart failure with reduced ejection fraction (HFrEF)
patients with or without T2DM. Ongoing study to evaluate the clinical effect of SGLTi for
heat failure with preserved ejection fraction (HFpEF) may further widen the clinical
implication of these novel cardiorenal protective drugs beyond their metabolic effects. In
this review, we summarized the updated clinical evidences on SGLT2i (rather than basic and
translational evidence) for reduction of HF risk in T2DM patients and favorable clinical
outcomes in both HFrEF and HFpEF patients. Results from cardiovascular outcome trials (CVOT) with 5 different sodium-glucose
co-transporter 2 inhibitors (SGLT2i; empagliflozin, canagliflozin, dapagliflozin,
ertugliflozin, sotagliflozin), initially developed for their glucose-lowering effect by
blocking tubular glucose reabsorption in kidney, have been shown to decrease the risk of
heart failure hospitalization (HFH) across a range of patients with and without
atherosclerotic cardiovascular disease in patients with type 2 diabetes mellitus (T2DM).
Following these CVOT results, SGLT2i (dapagliflozin, empagliflozin, sotagliflozin) also
were reported to reduce HFH and cardiovascular death in patients with heart failure with
reduced ejection fraction (HFrEF), regardless of existence or absence of T2DM. Ongoing
studies have been conducted to evaluate the clinical benefit of SGLT2i (empagliflozin,
dapagliflozin) in patients with heart failure with preserved ejection fraction (HFpEF).
Although SGLT2i brought us to the entrance of a new era for prevention of HF incidence and
worsening of HF, the search for pivotal mechanism of SGLT2i to improve our pharmacological
armamentarium should continue in order to protect every HF patient from fatal progression
of HF disease. In this review, we summarized the updated clinical evidences on SGLT2i
(rather than basic and translational evidence) for reduction of HF risk in T2DM patients
and favorable clinical outcomes in both HFrEF and HFpEF patients.
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Affiliation(s)
- Jaewon Oh
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.,Department of Biochemistry and Molecular Biology, Yonsei University College of Medicine, Seoul, Korea
| | - Chan Joo Lee
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Seok Min Kang
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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15
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Pellicori P, Ofstad AP, Fitchett D, Zeller C, Wanner C, George J, Zinman B, Brueckmann M, Lindenfeld J. Early benefits of empagliflozin in patients with or without heart failure: findings from EMPA-REG OUTCOME. ESC Heart Fail 2020; 7:3401-3407. [PMID: 32915523 PMCID: PMC7754994 DOI: 10.1002/ehf2.12891] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 06/19/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022] Open
Abstract
Aims The EMPA‐REG OUTCOME trial demonstrated reductions in cardiovascular (CV) death and heart failure (HF) outcomes with empagliflozin, a sodium–glucose co‐transporter 2 inhibitor, in patients with type 2 diabetes and established CV disease over a study period of 3 years. We aimed to investigate the early benefit–risk profile of empagliflozin in patients enrolled in the EMPA‐REG OUTCOME trial according to HF status at baseline. Methods and results The effects of treatments on glycated haemoglobin, systolic blood pressure and body weight, and on the HF endpoints of hospitalization for HF (HHF), HHF or CV death, and HHF or all‐cause mortality were evaluated at 12 weeks, 6 months, and 1 year after randomization. Occurrence of adverse events (AEs) during these time points was also evaluated. Compared with placebo, empagliflozin lowered glycated haemoglobin, systolic blood pressure, and body weight and rates of all the HF endpoints, as early as at 12 weeks, regardless of HF status at baseline. Favourable clinical and metabolic effects were maintained over time. AEs were generally higher in those with HF than without HF; however, compared with placebo, empagliflozin did not increase risk of developing AEs over the first year of treatment. Conclusions In the EMPA‐REG OUTCOME trial, the use of empagliflozin led to early and beneficial effects on clinical, metabolic, and HF outcomes in patients with type 2 diabetes with or without HF at baseline, which were already apparent within 12 weeks from initiation of treatment. Over the first year of treatment, no safety concern was detected with the use of empagliflozin.
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Affiliation(s)
- Pierpaolo Pellicori
- Robertson Centre for Biostatistics, Glasgow Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | | | - David Fitchett
- St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Christoph Wanner
- Department of Medicine, Würzburg University Clinic, Würzburg, Germany
| | - Jyothis George
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
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