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Sun Y, Lu B, Hu Y, Lv Y, Zhong S. Glycemic Variability in Pancreatogenic Diabetes Mellitus: characteristics, Risks, Potential Mechanisms, and Treatment Possibilities. Int J Gen Med 2024; 17:4297-4309. [PMID: 39324147 PMCID: PMC11423834 DOI: 10.2147/ijgm.s477497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 09/03/2024] [Indexed: 09/27/2024] Open
Abstract
In recent years, pancreatogenic diabetes mellitus has garnered significant attention due to its high incidence, complications, and mortality rates. Glycemic variability (GV) can increase the risk of pancreatogenic diabetes mellitus and its associated complications; however, the precise mechanism remains unclear. The effective control of GV is crucial for preventing the onset of pancreatic diabetes mellitus and improving prognosis. Both diet and antidiabetic medications have substantial effects on GV. However, many patients are prescribed suboptimal or even harmful drugs. Therefore, to provide a comprehensive treatment basis for clinicians to prevent and treat pancreatogenic diabetes mellitus, this study aimed to elucidate the relationship between GV and pancreatogenic diabetes mellitus; investigate the potential mechanisms (such as oxidative stress, inflammatory response, insulin resistance, and lipid metabolism disorders); provide lifestyle guidance; and recommend drug selections to reduce the GV in patients with pancreatogenic diabetes mellitus.
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Affiliation(s)
- Yuyan Sun
- Department of Endocrinology, Gusu School, Nanjing Medical University, The First People’s Hospital of Kunshan, Kunshan, 215300, People’s Republic of China
| | - Bing Lu
- Department of Endocrinology, Gusu School, Nanjing Medical University, The First People’s Hospital of Kunshan, Kunshan, 215300, People’s Republic of China
| | - Yuanwen Hu
- Department of Gastroenterology, The First People’s Hospital of Kunshan, Kunshan, 215300, People’s Republic of China
| | - Yingqi Lv
- Division of Endocrinology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, People’s Republic of China
| | - Shao Zhong
- Department of Endocrinology, Gusu School, Nanjing Medical University, The First People’s Hospital of Kunshan, Kunshan, 215300, People’s Republic of China
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Landgraf R, Aberle J, Birkenfeld AL, Gallwitz B, Kellerer M, Klein HH, Müller-Wieland D, Nauck MA, Wiesner T, Siegel E. Therapy of Type 2 Diabetes. Exp Clin Endocrinol Diabetes 2024; 132:340-388. [PMID: 38599610 DOI: 10.1055/a-2166-6755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
| | - Jens Aberle
- Division of Endocrinology and Diabetology, University Obesity Centre Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | | | - Baptist Gallwitz
- Department of Internal Medicine IV, Diabetology, Endocrinology, Nephrology, University Hospital Tübingen, Germany
| | - Monika Kellerer
- Department of Internal Medicine I, Marienhospital, Stuttgart, Germany
| | - Harald H Klein
- MVZ for Diagnostics and Therapy Bochum, Bergstraße 26, 44791 Bochum, Germany
| | - Dirk Müller-Wieland
- Department of Internal Medicine I, Aachen University Hospital RWTH, Aachen, Germany
| | - Michael A Nauck
- Diabetology, Endocrinology and Metabolism Section, Department of Internal Medicine I, St. Josef Hospital, Ruhr University, Bochum, Germany
| | | | - Erhard Siegel
- Department of Internal Medicine - Gastroenterology, Diabetology/Endocrinology and Nutritional Medicine, St. Josefkrankenhaus Heidelberg GmbH, Heidelberg, Germany
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Patır P, Çerçi K, Kurtoğlu E. Myeloproliferative Neoplasms and Sodium-Glucose Co-Transporter-2 Inhibitors: A Case Series. Turk J Haematol 2024; 41:130-132. [PMID: 38556957 DOI: 10.4274/tjh.galenos.2024.2024.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024] Open
Affiliation(s)
- Püsem Patır
- University of Health Sciences Türkiye, Antalya Training and Research Hospital, Clinic of Hematology, Antalya, Türkiye
| | - Kübra Çerçi
- University of Health Sciences Türkiye, Antalya Training and Research Hospital, Department of Internal Medicine, Antalya, Türkiye
| | - Erdal Kurtoğlu
- University of Health Sciences Türkiye, Antalya Training and Research Hospital, Clinic of Hematology, Antalya, Türkiye
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Bonacchi G, Rossi VA, Garofalo M, Mollace R, Uccello G, Pieragnoli P, Checchi L, Perrotta L, Voltolini L, Ricciardi G, Beltrami M. Pathophysiological Link and Treatment Implication of Heart Failure and Preserved Ejection Fraction in Patients with Chronic Kidney Disease. Biomedicines 2024; 12:981. [PMID: 38790943 PMCID: PMC11117953 DOI: 10.3390/biomedicines12050981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 05/26/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) results from a complex interplay of age, genetic, cardiac remodeling, and concomitant comorbidities including hypertension, obesity, diabetes, and chronic kidney disease (CKD). Renal failure is an important comorbidity of HFpEF, as well as a major pathophysiological mechanism for those patients at risk of developing HFpEF. Heart failure (HF) and CKD are intertwined conditions sharing common disease pathways; the so-called "kidney tamponade", explained by an increase in intracapsular pressure caused by fluid retention, is only the latest model to explain renal injury in HF. Recognizing the different phenotypes of HFpEF remains a real challenge; the pathophysiological mechanisms of renal dysfunction may differ across the HF spectrum, as well as the prognostic role. A better understanding of the role of cardiorenal interactions in patients with HF in terms of symptom status, disease progression, and prognosis remains essential in HF management. Historically, patients with HF and CKD have been scarcely represented in clinical trial populations. Current concerns affect the practical approach to HF treatment, and, in this context, physicians are frequently hesitant to prescribe and titrate both new and old treatments. Therefore, the extensive application of HF drugs in diverse HF subtypes with numerous comorbidities and different renal dysfunction etiologies remains a controversial matter of discussion. Numerous recently introduced drugs, such as sodium-glucose-linked transporter 2 inhibitors (SGLT2i), constitute a new therapeutic option for patients with HF and CKD. Because of their protective vascular and hormonal actions, the use of these agents may be safely extended to patients with renal dysfunction in the long term. The present review delves into the phenotype of patients with HFpEF and CKD from a pathophysiological perspective, proposing a treatment approach that suggests a practical stepwise algorithm for the proper application of life-saving therapies in clinical practice.
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Affiliation(s)
- Giacomo Bonacchi
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy;
| | | | - Manuel Garofalo
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Rocco Mollace
- Department of Experimental Medicine, Tor Vergata University, 00133 Rome, Italy;
- Cardiology Unit, Humanitas Gavazzeni, 24125 Bergamo, Italy
| | - Giuseppe Uccello
- Division of Cardiology, “A. Manzoni” Hospital—ASST Lecco, 23900 Lecco, Italy;
| | - Paolo Pieragnoli
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Luca Checchi
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Laura Perrotta
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Luca Voltolini
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
- Thoracic Surgery Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Giuseppe Ricciardi
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
| | - Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy;
- Arrhythmia and Electrophysiology Unit, Careggi University Hospital, 50134 Florence, Italy; (M.G.); (P.P.); (L.C.); (L.P.); (G.R.)
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Chen J, Jiang C, Guo M, Zeng Y, Jiang Z, Zhang D, Tu M, Tan X, Yan P, Xu X, Long Y, Xu Y. Effects of SGLT2 inhibitors on cardiac function and health status in chronic heart failure: a systematic review and meta-analysis. Cardiovasc Diabetol 2024; 23:2. [PMID: 38172861 PMCID: PMC10765651 DOI: 10.1186/s12933-023-02042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/22/2023] [Indexed: 01/05/2024] Open
Abstract
PURPOSE Numerous clinical studies have explored sodium-glucose cotransporter 2 inhibitor (SGLT2i) in patients with chronic heart failure (CHF), with or without type 2 diabetes mellitus (T2DM), and SGLT2i were proved to significantly reduce CHF hospitalization, cardiovascular death, cardiovascular mortality, all-cause mortality and myocardial infarction in patients with or without T2DM. However, only a limited few have investigated the effects of SGLT-2i on HF disease-specific health status and cardiac function. This meta-analysis aims to assess the effects of SGLT2i on disease-specific health status and cardiac function in CHF patients. METHODS A comprehensive search was conducted of trials by searching in PubMed, EMBASE, CENTRAL, Scopus, and Web of Science, and two Chinese databases (CNKI and Wanfang), Clinical Trials ( http://www. CLINICALTRIALS gov ) were also searched. RESULTS A total of 18 randomized controlled trials (RCTs) involving 23,953 participants were included in the meta-analysis. The effects of SGLT2 inhibitors were compared with control or placebo groups in CHF with or without T2DM. The SGLT2 inhibitors group exhibited a significant reduction in pro b-type natriuretic peptide (NT-proBNP) levels by 136.03 pg/ml (95% confidence interval [CI]: -253.36, - 18.70; P = 0.02). Additionally, a greater proportion of patients in the SGLT2 inhibitors group showed a ≥ 20% decrease in NT-proBNP (RR = 1.45, 95% CI [0.92, 2.29], p = 0.072). However, no statistically significant difference was observed for the effects on B-type natriuretic peptide (BNP). The use of SGLT-2 inhibitors led to a noteworthy improvement in LVEF by 2.79% (95% CI [0.18, 5.39];P = 0.036). In terms of health status, as assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ) and 6-minute walk distance, SGLT2 inhibitors led to a significant improvement in KCCQ clinical summary (KCCQ-CS) score (WMD = 1.7, 95% CI [1.67, 1.73], P < 0.00001), KCCQ overall summary (KCCQ-OS) score (WMD = 1.73, 95% CI [0.94, 2.52], P < 0.00001), and KCCQ total symptom (KCCQ-TS) score (WMD = 2.88, 95% CI [1.7, 4.06], P < 0.00001). Furthermore, the occurrence of KCCQ-CS and KCCQ-OS score increases ≥ 5 points had relative risks (RR) of 1.25 (95% CI [1.11, 1.42], P < 0.00001) and 1.15 (95% CI [1.09, 1.22], P < 0.00001), respectively. Overall, SGLT2 inhibitors increased the 6-minute walk distance by 23.98 m (95% CI [8.34, 39.62]; P = 0.003) compared to control/placebo from baseline. CONCLUSIONS The SGLT2 inhibitors treatment offers an effective strategy for improving NT-proBNP levels, Kansas City Cardiomyopathy Questionnaire scores and 6-minute walk distance in CHF with or without T2DM. These findings indicate that SGLT2i improve cardiac function and health status in CHF with or without T2DM, and provide valuable guidance for clinicians making treatment decisions for patients with CHF.
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Affiliation(s)
- Jiao Chen
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Department of Endocrinology, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, Luzhou, China
| | - Chunxia Jiang
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, Luzhou, China
- State Key Laboratory of Quality Research in Chinese Medicine, Macau University of Science and Technology, Macao, China
- Faculty of Chinese Medicine, Macau University of Science and Technology, Macao, China
| | - Man Guo
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, Luzhou, China
| | - Yan Zeng
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, Luzhou, China
| | - Zongzhe Jiang
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, Luzhou, China
| | - Dongmin Zhang
- Department of Endocrinology, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan, China
| | - Mengqin Tu
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, Luzhou, China
| | - Xiaozhen Tan
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, Luzhou, China
| | - Pijun Yan
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, Luzhou, China
| | - XunMei Xu
- Department of Endocrinology, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan, China.
| | - Yang Long
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China.
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, Luzhou, China.
| | - Yong Xu
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
- Sichuan Clinical Research Center for Nephropathy, Luzhou, Sichuan, China.
- Metabolic Vascular Disease Key Laboratory of Sichuan Province, Luzhou, China.
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Doğruel H, Atlım HT, Aydemir M, Yılmaz N, Sarı R. Comparative evaluation of clinical outcomes of dapagliflozin and empagliflozin in type-2 diabetes mellitus. Ir J Med Sci 2023; 192:2189-2195. [PMID: 36580225 DOI: 10.1007/s11845-022-03262-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/19/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Sodium-glucose transporter 2 (SGLT-2) inhibitors provide additional benefits besides glycemic control. AIM This study aims to compare the clinical outcomes of dapagliflozin and empagliflozin. METHODS This retrospective study evaluated data retrieved from medical records of patients who were under follow-up with the diagnosis of type 2 diabetes mellitus (T2DM) and were started on dapagliflozin or empagliflozin treatment between January 1, 2017, and June 1, 2020. Demographic features, comorbidities, clinical features, duration of diabetes, baseline, and follow-up laboratory test results were recorded. The significance level was set at p < 0.05. RESULTS This study comprised 342 patients who are on the treatment with dapagliflozin (n = 228) or empagliflozin (n = 114). The glycosylated hemoglobin a1c (HBA1C) level was significantly decreased in both the dapagliflozin (8.18-7.59, p < 0.001) and empagliflozin (8.35-7.58, p < 0.001) groups. The urine albumin-to-creatinine ratio (ACR) was also decreased in both groups. A decrease in urine ACR was observed independent of using a renin-angiotensin-aldosterone system (RAAS) blocker both in the whole group and in patients with diabetic nephropathy. The time to addition of a new anti-diabetic agent to the treatment was shorter in the dapagliflozin group (14.4 months vs 17.7 months, p = 0.041, respectively). CONCLUSION Dapagliflozin and empagliflozin are the drugs to choose for renoprotection in diabetics independent of the use of a RAAS blocker. Even the time to addition of a new anti-diabetic agent is longer in the empagliflozin group, head-to-head comparative trials are needed to asess the potential differences in this regard.
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Affiliation(s)
- Hakan Doğruel
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey
| | - Hatice Tülüce Atlım
- Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey
| | - Mustafa Aydemir
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey.
| | - Nusret Yılmaz
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey
| | - Ramazan Sarı
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, 07070, Turkey
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Iacoviello M, Marini M, Gori M, Orso F, Gonzini L, Gorini M, Fenici P, Maggioni AP. DAPA-HF applicability: the point of view of a cardiology setting. Acta Cardiol 2023; 78:840-845. [PMID: 37605991 DOI: 10.1080/00015385.2023.2243130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/18/2023] [Accepted: 07/27/2023] [Indexed: 08/23/2023]
Abstract
Randomised clinical trials, observational studies, and meta-analyses have shown that sodium-glucose cotransporter 2 inhibitors (SGLT2-i) reduce the risk of hospitalisation for heart failure (HF), chronic kidney disease (CKD) progression, and mortality in patients with HF, irrespective of the presence of type 2 diabetes mellitus. However, real-world epidemiology may differ from clinical trial populations, thereby limiting generalisability and delaying the introduction of novel treatments in clinical practice.The aim of the present study was to assess the prevalence of DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) inclusion criteria in a population of HF with reduced ejection fraction (HFrEF) patients enrolled in the Italian Network on Heart Failure (IN-HF) registry.Overall, 3415 IN-HF patients matched the 4744 patients in DAPA-HF, overlapping for most baseline characteristics (e.g. similar average ejection fraction), with a slightly lower prevalence of type 2 diabetes and of HF ischaemic aetiology and a higher percentage of NYHA class II patients. The theoretical eligibility to DAPA-HF in a cardiology setting resulted to be 73%.The availability of an easily accessible database from a large nationwide prospective registry allows to provide insights to clinicians and policy makers on the applicability of the DAPA HF findings to a contemporary population of HFrEF patients followed by cardiologists. It is reasonable to assume that the results of this analysis can be applicable to the entire SGLT2-ir class of drugs.
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Affiliation(s)
- Massimo Iacoviello
- Medical and Surgical Sciences Department, University of Foggia, Foggia, Italy
| | - Marco Marini
- Cardiovascular Sciences Cardiology Department, Ospedali Riuniti, Ancona, Italy
| | - Mauro Gori
- Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Orso
- Department of Experimental and Clinical Medicine, University of Florence and Cardiac Rehabilitation Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Lucio Gonzini
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Marco Gorini
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Peter Fenici
- Catholic University of the Sacred Heart, School of Medicine and Surgery, Rome, Italy
- Biomagnetism and Clinical Physiology International Center (BACPIC), Rome, Italy
- Medical Affairs, AstraZeneca S.p.A, Milan, Italy
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Scheen AJ. The current role of SGLT2 inhibitors in type 2 diabetes and beyond: a narrative review. Expert Rev Endocrinol Metab 2023; 18:271-282. [PMID: 37154218 DOI: 10.1080/17446651.2023.2210673] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/02/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Sodium-glucose cotransporter 2 inhibitors (SGLT2is, gliflozins), the most recent oral antihyperglycaemic agents, provide a cardiorenal protection, an effect independent of their glucose-lowering potency. AREAS COVERED The antihyperglycaemic potency of SGLT2is was compared with that of dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists, especially when added to metformin monotherapy. Main results of cardiovascular/renal outcome trials with SGLT2is were summarized in different populations: patients with type 2 diabetes mellitus (T2DM) with or without established cardiovascular disease, patients (with or without T2DM) with heart failure (with reduced or preserved left ventricular ejection fraction) and in patients (with or without T2DM) with chronic kidney disease (CKD, including stage 4). Original papers and meta-analyses of these different trials have consistently reported a reduction in hospitalization for heart failure (alone or combined with cardiovascular mortality) and a reduced progression of CKD, with an overall good safety profile. EXPERT OPINION Global use of SGLT2is has increased over time but remains suboptimal despite clinically relevant cardiovascular and renal protection, particularly in patients most likely to benefit. SGLT2is has proven both positive benefit-risk balance and cost-effectiveness in at risk patients. New prospects are expected in other complications, i.e. metabolic-associated fatty liver disease and neurodegenerative disorders.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium
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Roldan Munoz S, Postmus D, de Vries ST, Gross-Martirosyan L, Bahri P, Hillege H, Mol PGM. What Factors Make EU Regulators Want to Communicate Drug Safety Issues Related to SGLT2 Inhibitors? An Online Survey Study. Drug Saf 2023; 46:243-255. [PMID: 36790560 PMCID: PMC9988744 DOI: 10.1007/s40264-022-01270-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Previous studies have found differences in the communication of safety issues among medicines regulatory agencies. OBJECTIVES To explore (1) to what extent regulators' opinions regarding the need to communicate safety issues related to sodium-glucose cotransporter-2 (SGLT2) inhibitors might be influenced by their concern about the safety issue, and (2) whether regulators' concerns might be influenced by certain characteristics of the safety issue or by the demographic and professional characteristics and attitudes of the regulators. METHODS An online cross-sectional survey study with a rating-based conjoint analysis among clinical and pharmacovigilance assessors from the EU regulatory network was performed between April and June 2021. Regulators were invited by email, and participants were asked about their level of concern and their opinion regarding the need to communicate about 12 scenarios defined by four characteristics: adverse drug reaction, source of information, causality, and frequency. The outcomes for the first objective were to update the summary of product characteristics (SmPC; yes/no) and to send direct healthcare professional communications (DHPC; yes/no). The determinant was regulators' level of concern (range 0-100%). The outcome of the second objective was regulators' level of concern, and the determinants were the characteristics of the safety issue, demographic and professional characteristics, and attitudes of the regulators (beliefs about medicines and risk perception). RESULTS A total of 222 regulators completed the survey (64% women; mean age 46 ± 10 years). Depending on the scenario, 54-94% and 25-74% of the participants would update the SmPC or send a DHPC, respectively. The participants' level of concern influenced their opinions regarding the need to update the SmPC and send a DHPC (odds ratio (OR) 13.0; 95% confidence interval (CI) 7.8-21.7 and OR 13.6; 95% CI 9.5-19.2, respectively, for every 10% increase in the level of concern). All characteristics of the safety issue influenced the level of concern. Younger participants, women, and those working for Eastern European agencies had a higher level of concern than older participants, men, and those working in other regions. Beliefs about medicines and general risk perception also influenced their concern. CONCLUSIONS The opinion regarding the need to communicate safety issues was influenced by the concern of regulators. Regulators' concern was influenced by the characteristics of the safety issue, demographic characteristics, and attitudes. Diverse groups of experts regarding such factors would ensure that various views are incorporated in risk communication decisions.
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Affiliation(s)
- Sonia Roldan Munoz
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Douwe Postmus
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sieta T de Vries
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
| | | | - Priya Bahri
- European Medicines Agency, Amsterdam, The Netherlands
| | - Hans Hillege
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
| | - Peter G M Mol
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands.
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Diallo A, Carlos-Bolumbu M, Renard PE, Galtier F. Larger effect size in composite kidney outcomes than in major cardiovascular events associated with sodium-glucose cotransporter-2 (SGLT2) inhibitors compared with glucagon-like peptide-1 receptor agonists (GLP-1RAs): A pooled analysis of type 2 diabetes trials. Diabetes Obes Metab 2023; 25:166-176. [PMID: 36057779 PMCID: PMC10087851 DOI: 10.1111/dom.14859] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/16/2022] [Accepted: 08/29/2022] [Indexed: 12/14/2022]
Abstract
AIM To compare treatment effect sizes between a composite kidney outcome (CKO) and three-point major adverse cardiovascular event (MACE-3) outcomes with use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RAs), and to investigate the relationship between treatment effects on CKO and MACE-3 in patients with type 2 diabetes (T2D). MATERIALS AND METHODS We performed a MEDLINE database search up to December 31, 2021 to identify all placebo-controlled Phase 3 trials which investigated the efficacy of glucose-lowering interventions, and selected those reporting results for CKO and MACE-3. Hazard ratios (HRs) with 95% confidence intervals (CIs) for both outcomes were extracted for each trial, and we evaluated differences in treatment effect sizes by using a ratio of HRs (rHR): the HR for CKO to the HR for MACE-3. A random-effects meta-analysis was used to obtain the overall rHR across trials and according to subgroup. We investigated the relationship between treatment effects on CKO and MACE-3 using the coefficient of determination (R2 ) with weighted meta-regression. The study protocol was registered on PROSPERO (CRD42022299690). RESULTS A total of 12 studies fulfilled the prespecified criteria, and comprised a total of 104 987 patients with T2D. On average, treatment effect sizes were 17% greater for CKO than for MACE-3 (rHR 0.83, 95% CI 0.74 to 0.92; I2 = 50%; P = 0.03; τ2 = 0.0161), especially for trials of SGLT2 inhibitors compared with GLP-1RAs. For secondary outcomes, treatment effect size was 22%, 21%, 16% and 9% greater for CKO than for myocardial infarction, stroke, death from cardiovascular causes, and hospitalization for heart disease, respectively. MACE-3 and CKO were moderately correlated (ρ = 0.40; P = 0.21), and only 11% (95% CI 1% to 54%) of the variability in the MACE-3 effect could be explained by the variability in the CKO effect. CONCLUSION In T2D patients, treatment effect sizes were greater for kidney than for macrovascular (MACE-3) outcomes, with important differences according to the drugs considered. CKO and MACE-3 are independent. Caution must be taken when interpreting CKO in the absence of MACE-3 data.
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Affiliation(s)
- Alhassane Diallo
- INSERM, CIC 1411, Clinical Investigation Center 1411, INSERM, CHU Montpellier, Univ Montpellier, Montpellier Cedex 5, France
| | - Miguel Carlos-Bolumbu
- Department of Anaesthesia and Intensive Care, Urgences réanimation centre hospitalier Sud Essonnes CHSE, Paris, France
| | - Pr Eric Renard
- Department of Endocrinology and Diabetes, Montpellier University Hospital; INSERM CIC 1411 Clinical Investigation Centre, Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Florence Galtier
- INSERM, CIC 1411, Clinical Investigation Center 1411, INSERM, CHU Montpellier, Univ Montpellier, Montpellier Cedex 5, France
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11
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Peng X, Li L, Lin R, Wang X, Liu X, Li Y, Ma C, Ruan Y, Liu N. Empagliflozin Ameliorates Ouabain-Induced Na + and Ca 2+ Dysregulations in Ventricular Myocytes in an Na +-Dependent Manner. Cardiovasc Drugs Ther 2022; 37:461-469. [PMID: 34982348 DOI: 10.1007/s10557-021-07311-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a novel class of glucose-lowering agents that have improved clinical outcomes in patients with heart failure; however, their therapeutic mechanisms remain elusive. Although contradictory results have been reported, it has been proposed that improving Na+ homeostasis may be the underlying mechanism of action of SGLT2 inhibitors in heart failure treatment. This study explored whether empagliflozin ameliorates Na+ and Ca2+ handling disorders induced by ouabain in an Na+-dependent manner. METHODS Isolated ventricular myocytes of mice were incubated with ouabain to establish a cellular model of Na+ overload. Effects of empagliflozin on Na+ and Ca2+ handling were evaluated using an ionOptix system and a confocal microscope. Distinct cytosolic Na+ levels were established by incubating different ouabain concentrations (10, 50, and 100 μmol/L). RESULTS In the absence of ouabain, 1 μmol/L empagliflozin had a negligible impact on Na+ and Ca2+ handling in ventricular myocytes. Ouabain (50 μmol/L) significantly enhanced cytosolic Na+ levels and dysregulated Ca2+ handling, including an increased Ca2+ transient amplitude, elevated Ca2+ content in the sarcoplasmic reticulum, and enhanced spontaneous Ca2+ release normalized by treatment with 1 μmol/L empagliflozin within 10 min. All Na+ and Ca2+ handling abnormalities induced by ouabain were reversed by 1 μmol/L empagliflozin. The efficacy of empagliflozin was more potent at higher cytosolic Na+ levels. Pretreatment with the Na+/H+ exchanger (NHE) inhibitor (1 μmol/L cariporide) abolished the effects of empagliflozin. CONCLUSION Empagliflozin ameliorates ouabain-induced Na+ and Ca2+ handling disorders in a cytosolic Na+-dependent manner, potentially by inhibiting the NHE.
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Affiliation(s)
- Xiaodong Peng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Linling Li
- Department of Cardiology, Beijing ChuiYangLiu Hospital, Beijing, China
| | - Rong Lin
- North China Medical & Health Group XingTai Genernal Hospital, Xingtai, China
| | - Xuesi Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Xinmeng Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Yukun Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Yanfei Ruan
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China. .,National Clinical Research Center for Cardiovascular Diseases, Beijing, China.
| | - Nian Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China. .,National Clinical Research Center for Cardiovascular Diseases, Beijing, China.
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12
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Lopez LN, Wang W, Loomba L, Afkarian M, Butani L. Diabetic kidney disease in children and adolescents: an update. Pediatr Nephrol 2022; 37:2583-2597. [PMID: 34913986 PMCID: PMC9489564 DOI: 10.1007/s00467-021-05347-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/16/2021] [Accepted: 10/18/2021] [Indexed: 12/15/2022]
Abstract
Diabetic kidney disease (DKD), previously encountered predominantly in adult patients, is rapidly gaining center stage as a childhood morbidity and one that pediatric nephrologists are likely to encounter with increasing frequency. This is in large part due to the obesity epidemic and the consequent rise in type 2 diabetes in children and adolescents, as well as the more aggressive diabetes phenotype in today's youth with more rapid β-cell decline and faster development and progression of diabetes-related complications along with lower responsiveness to the treatments used in adults. DKD, an end-organ complication of diabetes, is at the very least a marker of, and more likely a predisposing factor for, the development of adverse cardiovascular outcomes and premature mortality in children with diabetes. On an optimistic note, several new therapeutic approaches are now available for the management of diabetes in adults, such as GLP1 receptor agonists, SGLT2 inhibitors, and DPP4 inhibitors, that have also been shown to have a favorable impact on cardiorenal outcomes. Also promising is the success of very low-energy diets in inducing remission of diabetes in adults. However, the addition of these pharmacological and dietary approaches to the management toolbox of diabetes and DKD in children and adolescents awaits thorough assessment of their safety and efficacy in this population. This review outlines the scope of diabetes and DKD, and new developments that may favorably impact the management of children and young adults with diabetes and DKD.
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Affiliation(s)
- Lauren N. Lopez
- Division of Nephrology, Department of Internal Medicine, University of California, Davis, Sacramento, CA USA
| | - Weijie Wang
- University of California, Berkeley, Berkeley, CA USA
| | - Lindsey Loomba
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California, Davis, Sacramento, CA USA
| | - Maryam Afkarian
- Division of Nephrology, Department of Internal Medicine, University of California, Davis, Sacramento, CA USA
| | - Lavjay Butani
- Division of Pediatric Nephrology, Department of Pediatrics, University of California, Davis, 2516 Stockton Blvd, Room 348, Sacramento, CA, 95817, USA.
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13
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Packer M, Zannad F, Butler J, Filippatos G, Ferreira JP, Pocock SJ, Brueckmann M, Zeller C, Hauske S, Anker SD. Influence of endpoint definitions on the effect of empagliflozin on major renal outcomes in the EMPEROR-Preserved trial. Eur J Heart Fail 2021; 23:1798-1799. [PMID: 34459076 PMCID: PMC9291539 DOI: 10.1002/ejhf.2334] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA.,Imperial College, London, UK
| | - Faiez Zannad
- Université de Lorraine, Inserm INI-CRCT, CHRU, Nancy, France
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Joao Pedro Ferreira
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA.,Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Martina Brueckmann
- Boehringer Ingelheim International, Ingelheim, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Cordula Zeller
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Sibylle Hauske
- Boehringer Ingelheim International, Ingelheim, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
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14
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Abushanab D, Liew D, Marquina C, Al-Badriyeh D, Ademi Z. Cost-Effectiveness of Empagliflozin and Metformin Combination Versus Standard Care as First-Line Therapy in Patients with Type 2 Diabetes Mellitus. Endocr Pract 2021; 28:16-24. [PMID: 34389513 DOI: 10.1016/j.eprac.2021.07.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been shown to reduce cardiovascular events, but are currently not used as first-line therapy. This study was conducted to evaluate the cost-effectiveness of first-line empagliflozin plus metformin versus metformin monotherapy among Australians with type 2 diabetes mellitus (T2DM) and existing cardiovascular disease (CVD). METHODS A Markov model with one-year cycles and a five-year time horizon was constructed to simulate the occurrence of recurrent cardiovascular events among Australians aged 50 to 84 years with T2DM and CVD. Efficacy results were derived from the EMPA-REG OUTCOME trial. Costs and utilities were drawn from published sources. The evaluation adopted both healthcare and societal perspectives, with the latter ascribing the Australian Government's 'value of statistical life year' (VoSLY, AUD 213,000) to each year lived by a person. Future outcomes were discounted at 5% annually. Sensitivity analyses were conducted to enhance robustness of conclusions. RESULTS Compared to metformin monotherapy, first-line empagliflozin plus metformin reduced overall cardiovascular events by 0.82% and overall deaths by 7.72% over five years. There were 0.2 years of life saved (YoLS) per person and 0.16 quality-adjusted life years (QALYs) gained, at a net healthcare cost of AUD 4,408. These equated to incremental cost-effectiveness ratios of AUD 22,076 per YoLS and AUD 28,244 per QALY gained. The gains in VoSLY equated to AUD 42,530 per person, meaning that from a societal perspective, the intervention was cost saving. CONCLUSION First-line empagliflozin plus metformin may represent a cost-effective strategy for the management of T2DM and CVD in Australia.
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Affiliation(s)
- Dina Abushanab
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Clara Marquina
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
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15
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Barbarawi M, Barbarawi O, Chen K. Response to letter to the editor regarding the article "SGLT2 inhibitors and cardiovascular and renal outcomes: a meta-analysis and trial sequential analysis" Cardiac, renal protection with SGLT2 inhibitors is evident but not in every diabetic patient. Heart Fail Rev 2021; 27:1469. [PMID: 33942211 DOI: 10.1007/s10741-021-10112-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Mahmoud Barbarawi
- Department of Cardiology, University of Connecticut, 263 Farmington Avenu, Farmington, CT, USA.
| | - Owais Barbarawi
- Department of Internal Medicine, Mutah University, Al-Karak, Jordan
| | - Kai Chen
- Department of Cardiology, University of Connecticut, 263 Farmington Avenu, Farmington, CT, USA
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16
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Qiu M, Ding LL, Zhan ZL, Zhou HR. Letter to the Editor regarding the article "SGLT2 inhibitors and cardiovascular and renal outcomes: a meta‑analysis and trial sequential analysis". Heart Fail Rev 2021; 27:981-982. [PMID: 33942210 DOI: 10.1007/s10741-021-10111-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] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Mei Qiu
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, 518110, China.
| | - Liang-Liang Ding
- Department of Endocrinology, First Affiliated Hospital of Yangtze University, Jingzhou, 434000, China
| | - Ze-Lin Zhan
- Class 3, Clinical medicine, Grade 2019, The Second Clinical Medical College, Southern Medical University, Guangzhou, China
| | - Hai-Rong Zhou
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen, 518110, China
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17
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Ferrannini G, Savarese G, Rydén L. Sodium-glucose transporter inhibition in heart failure: from an unexpected side effect to a novel treatment possibility. Diabetes Res Clin Pract 2021; 175:108796. [PMID: 33845051 DOI: 10.1016/j.diabres.2021.108796] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 03/30/2021] [Accepted: 04/02/2021] [Indexed: 12/17/2022]
Abstract
Sodium-glucose transporter-2 inhibitors (SGLT2i), originally launched as glucose-lowering drugs, have been studied in large cardiovascular outcome trials to ascertain safety. Surprisingly, these compounds reduced the risk of cardiovascular events (cardiovascular death, non-fatal myocardial and non-fatal stroke) and total mortality. The mechanisms behind this benefit are only partly understood, but a major contributor is the reduction of heart failure hospitalisations, evident already within weeks after the initiation of the SGLT2i. SGLT2 inhibition increases urinary glucose excretion, thereby improving glycaemic control in an insulin-independent manner. Moreover, SGLT2i potentially impact the cardiovascular system both indirectly via weight loss and blood pressure lowering and directly through osmotic diuresis and increased sodium excretion and presumably by improving myocardial energetics. The aim of this review is to summarise evidence from all major outcome trials investigating SGLT2i in patients with diabetes, as well as recent evidence from trials in heart failure patients without glucose perturbations, which pave the way for novel treatment of large groups of patients. The results of these studies have been taken into account in recently issued guidelines for the management of diabetes and cardiovascular disease. An important task for diabetologists, cardiologists and general practitioners is to incorporate them into clinical practice to the benefit of many patients.
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Affiliation(s)
- Giulia Ferrannini
- Department of Medicine K2, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Gianluigi Savarese
- Department of Medicine K2, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Lars Rydén
- Department of Medicine K2, Karolinska Institutet, 171 76 Stockholm, Sweden.
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