1
|
Inzucchi SE, Wanner C, Fitchett D, Zinman B, Anker SD, Pocock SJ, Mattheus M, Hantel S, Lund SS. Impact of empagliflozin on first and recurrent events leading to or prolonging hospitalisation in the EMPA-REG OUTCOME trial. Diabetes Res Clin Pract 2024; 212:111715. [PMID: 38777127 DOI: 10.1016/j.diabres.2024.111715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/07/2024] [Accepted: 05/19/2024] [Indexed: 05/25/2024]
Abstract
In EMPA-REG OUTCOME, empagliflozin reduced the composite of total events leading to/prolonging hospitalisation for any cause and all-cause mortality by 24 % versus placebo in patients with T2DM and ASCVD, with 67.7 events prevented/1000 patient-years and a low NNT. Effects were sustained and were consistent regardless of the reason for hospitalisation.
Collapse
Affiliation(s)
- Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA.
| | | | - David Fitchett
- St Michael's Hospital, Division of Cardiology, University of Toronto, ON, Canada
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site, Berlin, Germany; Charité Universitätsmedizin Berlin, Berlin, Germany; Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Stefan Hantel
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Søren S Lund
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| |
Collapse
|
2
|
Aldafas R, Crabtree T, Alkharaiji M, Vinogradova Y, Idris I. Sodium-glucose cotransporter-2 inhibitors (SGLT2) in frail or older people with type 2 diabetes and heart failure: a systematic review and meta-analysis. Age Ageing 2024; 53:afad254. [PMID: 38287703 PMCID: PMC10825241 DOI: 10.1093/ageing/afad254] [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: 08/18/2023] [Revised: 11/09/2023] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE Sodium-glucose cotransporter-2 inhibitors (SGLT2Is) reduce cardio-metabolic and renal outcomes in patients with type 2 diabetes (T2D) but their efficacy and safety in older or frail individuals remains unclear. METHODS We searched PubMed, Scopus, Web of Science, Cochrane CENTRA and Google Scholar and selected randomised controlled trials and observational studies comparing SGLT2Is versus placebo/other glucose-lowering agent for people with frailty or older individuals (>65 years) with T2D and heart failure (HF). Extracted data on the change in HbA1c % and safety outcomes were pooled in a random-effects meta-analysis model. RESULTS We included data from 20 studies (22 reports; N = 77,083 patients). SGLT2Is did not significantly reduce HbA1c level (mean difference -0.13, 95%CI: -0.41 to 0.14). SGLT2Is were associated with a significant reduction in the risk of all-cause mortality (risk ratio (RR) 0.81, 95%CI: -0.69 to 0.95), cardiac death (RR 0.80, 95%CI: -0.94 to 0.69) and hospitalisation for heart failure (HHF) (RR 0.69, 95%CI: 0.59-0.81). However, SGLT2Is did not demonstrate significant effect in reducing in the risk of macrovascular events (acute coronary syndrome or cerebral vascular occlusion), renal progression/composite renal endpoint, acute kidney injury, worsening HF, atrial fibrillation or diabetic ketoacidosis. CONCLUSIONS In older or frail patients with T2D and HF, SGLT2Is are consistently linked with a decrease in total mortality and the overall burden of cardiovascular (CV) events, including HHF events and cardiac death, but not protective for macrovascular death or renal events. Adverse events were more difficult to quantify but the risk of diabetic ketoacidosis or acute kidney injury was not significantly increase.
Collapse
Affiliation(s)
- Rami Aldafas
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Derby, UK
- Faculty of Public Health, College of Health Science, The Saudi Electronic University, Riyadh, Saudi Arabia
| | - Tomas Crabtree
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Derby, UK
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
| | - Mohammed Alkharaiji
- Faculty of Public Health, College of Health Science, The Saudi Electronic University, Riyadh, Saudi Arabia
| | - Yana Vinogradova
- Division of Primary Care, University of Nottingham, Nottingham NG2 7RD, UK
| | - Iskandar Idris
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Derby, UK
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, NIHR, Nottingham BRC, University of Nottingham, Derby, UK
| |
Collapse
|
3
|
Hinton W, Ansari AS, Whyte MB, McGovern AP, Feher MD, Munro N, de Lusignan S. Sodium-glucose co-transporter-2 inhibitors in type 2 diabetes: Are clinical trial benefits for heart failure reflected in real-world clinical practice? A systematic review and meta-analysis of observational studies. Diabetes Obes Metab 2023; 25:501-515. [PMID: 36239122 DOI: 10.1111/dom.14893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 02/02/2023]
Abstract
AIM To determine the absolute risk reduction (ARR) of heart failure events in people treated with sodium-glucose co-transporter-2 (SGLT2) inhibitors. MATERIALS AND METHODS We searched PubMed, EMBASE, CINAHL and ISI Web of Science for observational studies published to 9 May 2022 that explored the association between SGLT2 inhibitors and any indication for heart failure (including new diagnosis or hospitalization for heart failure) in type 2 diabetes. Identified studies were independently screened by two reviewers and assessed for bias using the Newcastle-Ottawa scale. Eligible studies with comparable outcome data were pooled for meta-analysis using random-effects models, reporting hazard ratios (HRs) with 95% confidence intervals (CIs). The ARR per 100 person-years was determined overall, and in subgroups with and without baseline cardiovascular disease (CVD). RESULTS From 43 eligible studies, with a total of 4 818 242 participants from 17 countries, 21 were included for meta-analysis. SGLT2 inhibitors were associated with a reduced risk of hospitalization for heart failure (HR 0.65, 95% CI 0.59-0.72) overall and both in those with CVD (HR 0.78, 95% CI 0.68-0.89) and without CVD (HR 0.53, 95% CI 0.39-0.71). Risk reduction for hospitalization for heart failure in people with a history of CVD (ARR 1.17, 95% CI 0.78-1.55) was significantly greater than for those without CVD (ARR 0.39, 95% CI 0.32-0.47). The number-needed-to-treat to prevent one event of hospitalization for heart failure was 86 (95% CI 65-128) person-years of treatment for the CVD group and 256 (95% CI 215-316) person-years for those without CVD. CONCLUSIONS Real-world SGLT2 inhibitor use supports randomized trial data for the size effect of reduced hospitalization for heart failure in type 2 diabetes, although with a much lower ARR in people without CVD.
Collapse
Affiliation(s)
- William Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Abdus Samad Ansari
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK
| | - Martin B Whyte
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Andrew P McGovern
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Michael D Feher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Neil Munro
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), London, UK
| |
Collapse
|
4
|
Schechter M, Fischer M, Mosenzon O. Preventing all-cause hospitalizations in type 2 diabetes with sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists: A narrative review and proposed clinical approach. Diabetes Obes Metab 2022; 24:969-982. [PMID: 35212443 PMCID: PMC9313801 DOI: 10.1111/dom.14675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/15/2022] [Accepted: 02/20/2022] [Indexed: 11/26/2022]
Abstract
Patients with type 2 diabetes (T2D) are at increased risk for hospital admissions, and acute hospitalizations are associated with a worse prognosis. However, outcomes related to all-cause hospital admissions (ACHAs) were often overlooked in trials that demonstrated the cardiovascular and kidney benefits of sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RAs). This review includes a contemporary literature summary of emerging data regarding the effects of SGLT2 inhibitors and GLP-1RAs on ACHAs. The role of SGLT2 inhibitors in preventing ACHAs was shown in exploratory investigations of several randomized controlled trials (RCTs) and was further supported by real-world evidence (RWE). However, the association between GLP-1RA use and lower ACHA risk was mainly shown through RWE, with minimal available RCT data. We also discuss the advantages and challenges of studying ACHAs. Finally, we propose an easily memorized ("ABCDE" acronym) clinical approach to evaluating T2D status and treatment in admitted patients, as they transition from hospital to community care. This systematic approach may assist clinicians in recognizing possible pitfalls in T2D management, thereby preventing subsequent hospitalizations and improving patient prognoses. While acute admission can sometimes be perceived as a management failure, it should also be viewed as an opportunity to take action to prevent the next hospitalization.
Collapse
Affiliation(s)
- Meir Schechter
- Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
- Diabetes Unit, Department of Endocrinology and MetabolismHadassah Medical CenterJerusalemIsrael
| | - Matan Fischer
- Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
- Department of Endocrinology and MetabolismHadassah Medical CenterJerusalemIsrael
- Department of internal medicine BHadassah Medical CenterJerusalemIsrael
| | - Ofri Mosenzon
- Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
- Diabetes Unit, Department of Endocrinology and MetabolismHadassah Medical CenterJerusalemIsrael
| |
Collapse
|
5
|
Charaya K, Shchekochikhin D, Andreev D, Dyachuk I, Tarasenko S, Poltavskaya M, Mesitskaya D, Bogdanova A, Ananicheva N, Kuzub A. Impact of dapagliflozin treatment on renal function and diuretics use in acute heart failure: a pilot study. Open Heart 2022; 9:openhrt-2021-001936. [PMID: 35609943 PMCID: PMC9131063 DOI: 10.1136/openhrt-2021-001936] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 05/02/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the impact of sodium-dependent glucose type 2 cotransporter inhibitors on the renal function in acute heart failure. METHODS In a single-centre, controlled, randomised study, patients were prescribed dapagliflozin in addition to standard therapy, or were in receipt of standard therapy. The prespecified outcome was renal function deterioration; the secondary outcomes were the development of resistance to diuretics, weight loss, death during hospitalisation and the rehospitalisation or death for any reason within 30 days following discharge. RESULTS 102 patients were included (73.4±11.7 years, 57.8% men). The average left ventricular ejection fraction was 44.9%±14.7%, the average N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was 4706 (1757; 11 244) pg/mL, the average estimated glomerular filtration rate (eGFR) was 51.6±19.5 mL/min. eGFR decreased 48 hours after randomisation in the dapagliflozin group (-4.2 (-11.03; 2.28) mL/min vs 0.3 (-6; 6) mL/min; p=0.04) but did not differ between the groups on discharge (54.71±19.18 mL/min and 58.92±24.65 mL/min; p=0.36). The incidence of worsening renal function did not differ (34.4% vs 15.2%; p=0.07). In the dapagliflozin group, there was less tendency to increase the dose of loop diuretics (14% vs 30%; p=0.048), lower average doses of loop diuretics (78.46±38.95 mg/day vs 102.82±31.26 mg/day; p=0.001) and more significant weight loss (4100 (2950; 5750) g vs 3000 (1380; 4650) g; p=0.02). In-hospital mortality was 7.8% (4(8%) in the dapagliflozin and 4 (7.7%) in the control group (p=0.95). The number of deaths within 30 days following discharge in the dapagliflozin group and in the control group was 9 (19%) and 12 (25%), p=0.55; the number of rehospitalisations was 14 (29%) and 17 (35%), respectively (p=0.51). CONCLUSION The use of dapagliflozin was associated with a more pronounced weight loss and less need to increase diuretic therapy without significant deterioration of the renal function. Dapagliflozin did not improve the in-hospital and 30-day prognosis after discharge. TRIAL REGISTRATION NUMBER N04778787.
Collapse
Affiliation(s)
- Kristina Charaya
- Department of Cardiology, Functional and Ultrasound Diagnostics, Sechenov University, Moskva, Moskva, Russian Federation
| | - Dmitry Shchekochikhin
- Department of Cardiology, Functional and Ultrasound Diagnostics, Sechenov University, Moskva, Moskva, Russian Federation
| | - Denis Andreev
- Department of Cardiology, Functional and Ultrasound Diagnostics, Sechenov University, Moskva, Moskva, Russian Federation
| | - Irina Dyachuk
- Department of Cardiology, Functional and Ultrasound Diagnostics, Sechenov University, Moskva, Moskva, Russian Federation
| | - Svetlana Tarasenko
- Department of Cardiology, Functional and Ultrasound Diagnostics, Sechenov University, Moskva, Moskva, Russian Federation
| | - Maria Poltavskaya
- Department of Cardiology, Functional and Ultrasound Diagnostics, Sechenov University, Moskva, Moskva, Russian Federation
| | - Dinara Mesitskaya
- Department of Cardiology, Functional and Ultrasound Diagnostics, Sechenov University, Moskva, Moskva, Russian Federation
| | - Alexandra Bogdanova
- Department of Cardiology, Functional and Ultrasound Diagnostics, Sechenov University, Moskva, Moskva, Russian Federation
| | - Natalia Ananicheva
- Department of Cardiology, Functional and Ultrasound Diagnostics, Sechenov University, Moskva, Moskva, Russian Federation
| | - Alina Kuzub
- Department of Cardiology, Functional and Ultrasound Diagnostics, Sechenov University, Moskva, Moskva, Russian Federation
| |
Collapse
|
6
|
Scheen AJ, Delanaye P. Acute renal injury events in diabetic patients treated with SGLT2 inhibitors: A comprehensive review with a special reference to RAAS blockers. DIABETES & METABOLISM 2021; 48:101315. [PMID: 34910981 DOI: 10.1016/j.diabet.2021.101315] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/03/2021] [Indexed: 01/13/2023]
Abstract
Renin-angiotensin-aldosterone system (RAAS) blockers and sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are two pharmacological classes that proved a remarkable nephroprotective effect, yet a risk of acute kidney injury (AKI) was also pointed out. In 2016, the US Food and Drug Administration recommended caution with the concomitant use of these medications. While the literature devoted to RAAS blockers remained surprisingly limited, numerous articles were published in recent years with SGLT2is. Safety analyses of large prospective cardiorenal trials showed a reduced rather than an increased number of AKI events in patients with type 2 diabetes treated with SGLT2is compared with those treated with placebo, despite the fact that a majority of patients received RAAS blockers at baseline. Interestingly, retrospective observational studies confirmed these reassuring findings in real-life conditions in more heterogeneous and possibly more frailty populations also commonly treated with RAAS blockers by showing a reduced risk of AKI with SGLT2is compared with other glucose-lowering drugs. Currently, there are no evidence of an increased risk of AKI with RAAS blocker-SGLT2i combinations in absence of haemodynamic instability. Several underlying mechanisms could explain a decreased rather than an increased risk of AKI with SGLT2is, including in patients treated with RAAS blockers.
Collapse
Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium; Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège (ULiege), Liège, Belgium.
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège (ULiege), CHU Sart Tilman, Liège, Belgium; Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nîmes, France
| |
Collapse
|