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Nikolaidou A, Ventoulis I, Karakoulidis G, Anastasiou V, Daios S, Papadopoulos SF, Didagelos M, Parissis J, Karamitsos T, Kotsa K, Ziakas A, Kamperidis V. Hypoglycemic Drugs in Patients with Diabetes Mellitus and Heart Failure: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:912. [PMID: 38929529 PMCID: PMC11205945 DOI: 10.3390/medicina60060912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 06/28/2024]
Abstract
Over the last few years, given the increase in the incidence and prevalence of both type 2 diabetes mellitus (T2DM) and heart failure (HF), it became crucial to develop guidelines for the optimal preventive and treatment strategies for individuals facing these coexisting conditions. In patients aged over 65, HF hospitalization stands out as the predominant reason for hospital admissions, with their prognosis being associated with the presence or absence of T2DM. Historically, certain classes of glucose-lowering drugs, such as thiazolidinediones (rosiglitazone), raised concerns due to an observed increased risk of myocardial infarction (MI) and cardiovascular (CV)-related mortality. In response to these concerns, regulatory agencies started requiring CV outcome trials for all novel antidiabetic agents [i.e., dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors), glucagon-like peptide-1 receptor agonists (GLP-1 RAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2is)] with the aim to assess the CV safety of these drugs beyond glycemic control. This narrative review aims to address the current knowledge about the impact of glucose-lowering agents used in T2DM on HF prevention, prognosis, and outcome.
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Affiliation(s)
- Anastasia Nikolaidou
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, Keptse Area, 50200 Ptolemaida, Greece;
| | - Georgios Karakoulidis
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Vasileios Anastasiou
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Stylianos Daios
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Spyridon-Filippos Papadopoulos
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Matthaios Didagelos
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - John Parissis
- Emergency Medicine Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 10679 Athens, Greece;
| | - Theodoros Karamitsos
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism, Diabetes Center, 1st Department of Internal Medicine, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Antonios Ziakas
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
| | - Vasileios Kamperidis
- 1st Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece; (A.N.); (G.K.); (V.A.); (S.D.); (S.-F.P.); (M.D.); (T.K.); (A.Z.)
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Chun KH, Oh J, Lee CJ, Park JJ, Lee SE, Kim MS, Cho HJ, Choi JO, Lee HY, Hwang KK, Kim KH, Yoo BS, Choi DJ, Baek SH, Jeon ES, Kim JJ, Cho MC, Chae SC, Oh BH, Kang SM. Metformin treatment is associated with improved survival in diabetic patients hospitalized with acute heart failure: A prospective observational study using the Korean acute heart failure registry data. DIABETES & METABOLISM 2024; 50:101504. [PMID: 38097010 DOI: 10.1016/j.diabet.2023.101504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 11/24/2023] [Accepted: 12/10/2023] [Indexed: 12/18/2023]
Abstract
AIMS Although the hypothesis that metformin is beneficial for patients with diabetes and heart failure (HF) has been steadily raised, there is limited data on metformin use in patients with acute HF. We analyzed the association of metformin on all-cause mortality in hospitalized patients with type 2 diabetes and acute HF. METHODS The Korean Acute Heart Failure registry prospectively enrolled patients hospitalized for acute HF from 2011 to 2014. Among this cohort, we analyzed patients with diabetes with baseline estimated glomerular filtration rate (eGFR) of 30 ml/min/1.73 m2 or more. We analyzed the all-cause mortality and re-hospitalization for HF within 1 year after discharge. Inverse probability treatment weighting method was used to adjust baseline differences on metformin treatment. RESULTS The study analyzed data from 1,309 patients with HF and diabetes (mean age 69 years, 56 % male). Among them, 613 (47 %) patients were on metformin at admission. During the median follow-up period of 11 months, 132 (19 %) and 74 (12 %) patients not receiving and receiving metformin treatment died, respectively. The mortality rate was lower in metformin users than in non-users (hazard ratio 0.616 [0.464-0.819] P<0.001). After adjustment, metformin was significantly associated with a lower risk for the mortality (hazard ratio 0.677 [0.495-0.928] P=0.015). In subgroup analyses, this association remains significant irrespective of baseline kidney function (eGFR <60 or ≥60 ml/min/1.73 m2, P-for-interaction=0.176) or left ventricular ejection fraction (<40 %, 40-49 %, or ≥50 %, P-for-interaction=0.224). CONCLUSIONS Metformin treatment at the time of admission was associated with a lower risk for 1-year mortality in patients with diabetes, hospitalized for acute HF.
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Affiliation(s)
- Kyeong-Hyeon Chun
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Jaewon Oh
- Cardiology Division, Severance Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chan Joo Lee
- Cardiology Division, Severance Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Joo Park
- Division of Cardiology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sang Eun Lee
- Division of Cardiology, Asan Medical Center, Seoul, Republic of Korea
| | - Min-Seok Kim
- Division of Cardiology, Asan Medical Center, Seoul, Republic of Korea
| | - Hyun-Jai Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin-Oh Choi
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Republic of Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung-Kuk Hwang
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Kye Hun Kim
- Department of Internal Medicine, Chonnam National University, Gwangju, Republic of Korea
| | - Byung-Su Yoo
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Dong-Ju Choi
- Division of Cardiology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sang Hong Baek
- Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun-Seok Jeon
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Republic of Korea
| | - Jae-Joong Kim
- Division of Cardiology, Asan Medical Center, Seoul, Republic of Korea
| | - Myeong-Chan Cho
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Shung Chull Chae
- Department of Internal Medicine, Kyungpook National University College of Medicine, Daegu, Republic of Korea
| | - Byung-Hee Oh
- Department of Internal Medicine, Mediplex Sejong Hospital, Incheon, Republic of Korea
| | - Seok-Min Kang
- Cardiology Division, Severance Hospital, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Zullo AR, Riester MR, Hayes KN, Munshi MN, Berry SD. Comparative safety of sulfonylureas among U.S. nursing home residents. J Am Geriatr Soc 2023; 71:1047-1057. [PMID: 36495141 PMCID: PMC10089954 DOI: 10.1111/jgs.18160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/23/2022] [Accepted: 10/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The comparative safety of sulfonylureas (SUs) in nursing home (NH) residents remains understudied despite widespread use. We compared the effects of three SU medications and initial SU doses on adverse glycemic and cardiovascular events among NH residents. METHODS This national retrospective cohort study linked Medicare claims with Minimum Data Set 2.0 assessments for long-stay NH residents aged ≥65 years between January 2008 and September 2010. Exposures were the SU medication initiated (glimepiride, glipizide, or glyburide) and doses (standard or reduced). One-year outcomes were hospitalizations or emergency department visits for severe hypoglycemia, heart failure (HF), stroke, and acute myocardial infarction (AMI). After the inverse probability of treatment and inverse probability of censoring by death weighting, we estimated hazard ratios (HR) using Cox regression models with robust 95% confidence intervals (CI). RESULTS The cohort (N = 6821) included 3698 new glipizide, 1754 glimepiride, and 1369 glyburide users. Overall, the mean (standard deviation) age was 81.4 (8.2) years, 4816 (70.6%) were female, and 5164 (75.7%) were White non-Hispanic residents. The rates of severe hypoglycemia were 30.3 (95% CI 22.3-40.1), 49.0 (95% CI 34.5-67.5), and 35.9 (95% CI 22.2-54.9) events per 1000 person-years among new glipizide, glimepiride, and glyburide users, respectively (glimepiride versus glipizide HR 1.6, 95% CI 1.0-2.4, p = 0.04; glyburide versus glipizide HR 1.2, 95% CI 0.7-1.9, p = 0.59). The rates of severe hypoglycemia were 27.1 (95% CI 18.6-38.0) and 42.8 (95% CI 33.6-53.8) events per 1000 person-years among new users of reduced and standard SU doses, respectively (HR 2.2, 95% CI 1.4-3.5, p < 0.01). Rates of HF, stroke, and AMI were similar between medications and doses. CONCLUSIONS Among long-stay NH residents, new use of glimepiride and standard SU doses resulted in higher rates of severe hypoglycemic events. Cardiovascular outcomes may not be affected by the choice of SU medication or dose.
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Affiliation(s)
- Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Pharmacy, Lifespan—Rhode Island Hospital, Providence, RI, USA
| | - Melissa R. Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kaleen N. Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Graduate Department of Pharmaceutical Sciences, University of Toronto Leslie Dan Faculty of Pharmacy, Toronto, Ontario, Canada
| | - Medha N. Munshi
- Joslin Diabetes Center, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sarah D. Berry
- Beth Israel Deaconess Medical Center, Boston, MA, USA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
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The neuroprotective and antidiabetic effects of trigonelline: A review of signaling pathways and molecular mechanisms. Biochimie 2023; 206:93-104. [PMID: 36257493 DOI: 10.1016/j.biochi.2022.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/07/2022] [Accepted: 10/12/2022] [Indexed: 11/23/2022]
Abstract
The global epidemic of diabetes has brought heavy pressure on public health. New effective anti-diabetes strategies are urgently needed. Trigonelline is the main component of fenugreek, which has been proved to have a good therapeutic effect on diabetes and diabetic complications. Trigonelline achieves amelioration of diabetes, the mechanisms of which include the modulation of insulin secretion, a reduction in oxidative stress, and the improvement of glucose tolerance and insulin resistance. Besides, trigonelline has been reported to be a neuroprotective agent against many neurologic diseases including Alzheimer's disease, Parkinson's disease, stroke, and depression. Concerning the potential therapeutic effects of trigonelline, comprehensive clinical trials are warranted to evaluate this valuable molecule.
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Kushner PR, Cavender MA, Mende CW. Role of Primary Care Clinicians in the Management of Patients With Type 2 Diabetes and Cardiorenal Diseases. Clin Diabetes 2022; 40:401-412. [PMID: 36381309 PMCID: PMC9606551 DOI: 10.2337/cd21-0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Individuals with type 2 diabetes are at increased risk of both renal and cardiovascular events. The convergence of type 2 diabetes, chronic kidney disease, and cardiovascular disease, including heart failure, requires management by a multidisciplinary health care team. Primary care clinicians are likely to be the first and most frequent point of contact for individuals with type 2 diabetes who are at high risk of cardiorenal disease and therefore play a pivotal role in early diagnosis, establishment of effective treatment strategies, and coordination of care. This article presents a clinical perspective with multidisciplinary collaboration on a patient case representative of those seen in routine clinical practice. The authors assess reasons why patients may not receive evidence-based care and identify opportunities to initiate therapies that reduce cardiovascular and renal events in the primary care setting.
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Affiliation(s)
- Pamela R. Kushner
- University of California, Irvine, CA
- Corresponding author: Pamela R. Kushner,
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Effects of Metformin in Heart Failure: From Pathophysiological Rationale to Clinical Evidence. Biomolecules 2021; 11:biom11121834. [PMID: 34944478 PMCID: PMC8698925 DOI: 10.3390/biom11121834] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/26/2021] [Accepted: 12/01/2021] [Indexed: 12/20/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a worldwide major health burden and heart failure (HF) is the most common cardiovascular (CV) complication in affected patients. Therefore, identifying the best pharmacological approach for glycemic control, which is also useful to prevent and ameliorate the prognosis of HF, represents a crucial issue. Currently, the choice is between the new drugs sodium/glucose co-transporter 2 inhibitors that have consistently shown in large CV outcome trials (CVOTs) to reduce the risk of HF-related outcomes in T2DM, and metformin, an old medicament that might end up relegated to the background while exerting interesting protective effects on multiple organs among which include heart failure. When compared with other antihyperglycemic medications, metformin has been demonstrated to be safe and to lower morbidity and mortality for HF, even if these results are difficult to interpret as they emerged mainly from observational studies. Meta-analyses of randomized controlled clinical trials have not produced positive results on the risk or clinical course of HF and sadly, large CV outcome trials are lacking. The point of force of metformin with respect to new diabetic drugs is the amount of data from experimental investigations that, for more than twenty years, still continues to provide mechanistic explanations of the several favorable actions in heart failure such as, the improvement of the myocardial energy metabolic status by modulation of glucose and lipid metabolism, the attenuation of oxidative stress and inflammation, and the inhibition of myocardial cell apoptosis, leading to reduced cardiac remodeling and preserved left ventricular function. In the hope that specific large-scale trials will be carried out to definitively establish the metformin benefit in terms of HF failure outcomes, we reviewed the literature in this field, summarizing the available evidence from experimental and clinical studies reporting on effects in heart metabolism, function, and structure, and the prominent pathophysiological mechanisms involved.
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Colburn TD, Weber RE, Schulze KM, Sue Hageman K, Horn AG, Behnke BJ, Poole DC, Musch TI. Sexual dimorphism in vascular ATP-sensitive K + channel function supporting interstitial PO2 via convective and/or diffusive O 2 transport. J Physiol 2021; 599:3279-3293. [PMID: 34101850 PMCID: PMC8451062 DOI: 10.1113/jp281120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/14/2021] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS Inhibition of pancreatic ATP-sensitive K+ (KATP ) channels is the intended effect of oral sulphonylureas to increase insulin release in diabetes. However, pertinent to off-target effects of sulphonylurea medication, sex differences in cardiac KATP channel function exist, whereas potential sex differences in vascular KATP channel function remain unknown. In the present study, we assessed vascular KATP channel function (topical glibenclamide superfused onto fast-twitch oxidative skeletal muscle) supporting blood flow and interstitial O2 delivery-utilization matching ( P O 2 is) during twitch contractions in male, female during pro-oestrus and ovariectomized female (F+OVX) rats. Glibenclamide decreased blood flow (convective O2 transport) and interstitial P O 2 in male and female, but not F+OVX, rats. Compared to males, females also demonstrated impaired diffusive O2 transport and a faster fall in interstitial P O 2 . Our demonstration, in rats, that sex differences in vascular KATP channel function exist support the tentative hypothesis that oral sulphonylureas may exacerbate exercise intolerance and morbidity, especially in premenopausal females. ABSTRACT Vascular ATP-sensitive K+ (KATP ) channels support skeletal muscle blood flow ( Q ̇ m ), interstitial O2 delivery ( Q ̇ O 2 )-utilization ( V ̇ O 2 ) matching (i.e. interstitial-myocyte O2 flux driving pressure; P O 2 is) and exercise tolerance. Potential sex differences in skeletal muscle vascular KATP channel function remain largely unexplored. We hypothesized that local skeletal muscle KATP channel inhibition via glibenclamide superfusion (5 mg kg-1 GLI; sulphonylurea diabetes medication) in anaesthetized female Sprague-Dawley rats, compared to males, would demonstrate greater reductions in contracting (1 Hz, 7 V, 180 s) fast-twitch oxidative mixed gastrocnemius (97% type IIA+IID/X+IIB) Q ̇ m (15 μm microspheres) and P O 2 is (phosphorescence quenching), resulting from more compromised convective ( Q ̇ O 2 ) and diffusive ( D O 2 ) O2 conductances. Furthermore, these GLI-induced reductions in ovary-intact females measured during pro-oestrus would be diminished following ovariectomy (F+OVX). GLI similarly impaired mixed gastrocnemius V ̇ O 2 in both males (↓28%) and females (↓33%, both P < 0.032) via reduced Q ̇ m (male: ↓31%, female: ↓35%, both P < 0.020), Q ̇ O 2 (male: 5.6 ± 0.5 vs. 4.0 ± 0.5, female: 6.4 ± 1.1 vs. 4.2 ± 0.6 mL O2 min-1 100 g tissue-1 , P < 0.022) and the resulting P O 2 is, with females also demonstrating a reduced D O 2 (0.40 ± 0.07 vs. 0.30 ± 0.04 mL O2 min-1 100 g tissue-1 , P < 0.042) and a greater GLI-induced speeding of P O 2 is fall (mean response time: Sex × Drug interaction, P = 0.026). Conversely, GLI did not impair the mixed gastrocnemius of F+OVX rats. Therefore, in patients taking sulphonylureas, these results support the potential for impaired vascular KATP channel function to compromise muscle Q ̇ m and therefore exercise tolerance. Such an effect, if present, would likely contribute to adverse cardiovascular events in premenopausal females more than males.
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Affiliation(s)
- Trenton D. Colburn
- Department of Kinesiology, Physiology, Kansas State University, Manhattan, KS, 66506, USA
| | - Ramona E. Weber
- Department of Kinesiology, Physiology, Kansas State University, Manhattan, KS, 66506, USA
| | - Kiana M. Schulze
- Department of Kinesiology, Physiology, Kansas State University, Manhattan, KS, 66506, USA
| | - K. Sue Hageman
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, 66506, USA
| | - Andrew G. Horn
- Department of Kinesiology, Physiology, Kansas State University, Manhattan, KS, 66506, USA
| | - Brad J. Behnke
- Department of Kinesiology, Physiology, Kansas State University, Manhattan, KS, 66506, USA
| | - David C. Poole
- Department of Kinesiology, Physiology, Kansas State University, Manhattan, KS, 66506, USA
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, 66506, USA
| | - Timothy I. Musch
- Department of Kinesiology, Physiology, Kansas State University, Manhattan, KS, 66506, USA
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, 66506, USA
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Avogaro A, Barillà F, Cavalot F, Consoli A, Federici M, Mancone M, Paolillo S, Pedrinelli R, Perseghin G, Perrone Filardi P, Scicali R, Sinagra G, Spaccarotella C, Indolfi C, Purrello F. Cardiovascular risk management in type 2 diabetes mellitus: A joint position paper of the Italian Cardiology (SIC) and Italian Diabetes (SID) Societies. Nutr Metab Cardiovasc Dis 2021; 31:1671-1690. [PMID: 33994263 DOI: 10.1016/j.numecd.2021.02.029] [Citation(s) in RCA: 3] [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: 02/20/2021] [Accepted: 02/23/2021] [Indexed: 12/12/2022]
Abstract
AIM This review represents a joint effort of the Italian Societies of Cardiology (SIC) and Diabetes (SID) to define the state of the art in a field of great clinical and scientific interest which is experiencing a moment of major cultural advancements, the cardiovascular risk management in type 2 diabetes mellitus. DATA SYNTHESIS Consists of six chapters that examine various aspects of pathophysiology, diagnosis and therapy which in recent months have seen numerous scientific innovations and several clinical studies that require extensive sharing. CONCLUSIONS The continuous evolution of our knowledge in this field confirms the great cultural vitality of these two cultural spheres, which requires, under the leadership of the scientific Societies, an ever greater and effective collaboration.
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Affiliation(s)
- Angelo Avogaro
- Dipartimento di Medicina, Sezione di Diabete e Malattia del Metabolismo, Università di Padova, Italy
| | - Francesco Barillà
- Dipartimento di Medicina dei Sistemi, Università di Roma Tor Vergata, Italy
| | - Franco Cavalot
- SSD Malattie Metaboliche e Diabetologia, AOU San Luigi Gonzaga, Orbassano (Torino), Italy
| | - Agostino Consoli
- Department of Medicine and Ageing Sciences and CeSI-Met, University D'Annunzio, Chieti, Italy
| | - Massimo Federici
- Dipartimento di Medicina dei Sistemi, Università di Roma Tor Vergata, Italy
| | - Massimo Mancone
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Policlinico Umberto I (Roma), Italy
| | - Stefania Paolillo
- Dipartimento di Scienze Biomediche Avanzate, Sezione di Cardiologia, Università degli Studi di Napoli Federico II, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Roberto Pedrinelli
- Dipartimento di Patologia Chirurgica, Medica, Molecolare e dell'Area Critica, Università di Pisa, Italy
| | - Gianluca Perseghin
- Dipartimento di Medicina e Riabilitazione, Policlinico di Monza, Università degli Studi di Milano Bicocca, Italy
| | - Pasquale Perrone Filardi
- Dipartimento di Scienze Biomediche Avanzate, Sezione di Cardiologia, Università degli Studi di Napoli Federico II, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Roberto Scicali
- Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department 'Ospedali Riuniti' and University of Trieste, Trieste, Italy
| | | | - Ciro Indolfi
- Division of Cardiology, University Magna Graecia, Catanzaro, Italy; Mediterranea Cardiocentro, Napoli, Italy.
| | - Francesco Purrello
- Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Italy.
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Sohrabi C, Saberwal B, Lim WY, Tousoulis D, Ahsan S, Papageorgiou N. Heart Failure in Diabetes Mellitus: An Updated Review. Curr Pharm Des 2020; 26:5933-5952. [PMID: 33213313 DOI: 10.2174/1381612826666201118091659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023]
Abstract
Diabetes mellitus (DM) and heart failure (HF) are comorbid conditions associated with significant morbidity and mortality worldwide. Despite the availability of novel and effective therapeutic options and intensive glycaemic control strategies, mortality and hospitalisation rates continue to remain high and the incidence of HF persists. In this review, we described the impact of currently available glucose-lowering therapies in DM with a focus on HF clinical outcomes. Non-conventional modes of management and alternative pathophysiological mechanisms with the potential for therapeutic targeting are also discussed.
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Affiliation(s)
- Catrin Sohrabi
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Bunny Saberwal
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Wei-Yao Lim
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Dimitris Tousoulis
- First Cardiology Department, Hippokration Hospital, Athens University Medical School, Athens, Greece
| | - Syed Ahsan
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Nikolaos Papageorgiou
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, United Kingdom
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Colburn TD, Weber RE, Hageman KS, Caldwell JT, Schulze KM, Ade CJ, Behnke BJ, Poole DC, Musch TI. Vascular ATP-sensitive K + channels support maximal aerobic capacity and critical speed via convective and diffusive O 2 transport. J Physiol 2020; 598:4843-4858. [PMID: 32798233 PMCID: PMC7874302 DOI: 10.1113/jp280232] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/13/2020] [Indexed: 12/26/2022] Open
Abstract
KEY POINTS Oral sulphonylureas, widely prescribed for diabetes, inhibit pancreatic ATP-sensitive K+ (KATP ) channels to increase insulin release. However, KATP channels are also located within vascular (endothelium and smooth muscle) and muscle (cardiac and skeletal) tissue. We evaluated left ventricular function at rest, maximal aerobic capacity ( V ̇ O2 max) and submaximal exercise tolerance (i.e. speed-duration relationship) during treadmill running in rats, before and after systemic KATP channel inhibition via glibenclamide. Glibenclamide impaired critical speed proportionally more than V ̇ O2 max but did not alter resting cardiac output. Vascular KATP channel function (topical glibenclamide superfused onto hindlimb skeletal muscle) resolved a decreased blood flow and interstitial PO2 during twitch contractions reflecting impaired O2 delivery-to-utilization matching. Our findings demonstrate that systemic KATP channel inhibition reduces V ̇ O2 max and critical speed during treadmill running in rats due, in part, to impaired convective and diffusive O2 delivery, and thus V ̇ O2 , especially within fast-twitch oxidative skeletal muscle. ABSTRACT Vascular ATP-sensitive K+ (KATP ) channels support skeletal muscle blood flow and microvascular oxygen delivery-to-utilization matching during exercise. However, oral sulphonylurea treatment for diabetes inhibits pancreatic KATP channels to enhance insulin release. Herein we tested the hypotheses that: i) systemic KATP channel inhibition via glibenclamide (GLI; 10 mg kg-1 i.p.) would decrease cardiac output at rest (echocardiography), maximal aerobic capacity ( V ̇ O2 max) and the speed-duration relationship (i.e. lower critical speed (CS)) during treadmill running; and ii) local KATP channel inhibition (5 mg kg-1 GLI superfusion) would decrease blood flow (15 µm microspheres), interstitial space oxygen pressures (PO2 is; phosphorescence quenching) and convective and diffusive O2 transport ( Q ̇ O2 and DO2 , respectively; Fick Principle and Law of Diffusion) in contracting fast-twitch oxidative mixed gastrocnemius muscle (MG: 9% type I+IIa fibres). At rest, GLI slowed left ventricular relaxation (2.11 ± 0.59 vs. 1.70 ± 0.23 cm s-1 ) and decreased heart rate (321 ± 23 vs. 304 ± 22 bpm, both P < 0.05) while cardiac output remained unaltered (219 ± 64 vs. 197 ± 39 ml min-1 , P > 0.05). During exercise, GLI reduced V ̇ O2 max (71.5 ± 3.1 vs. 67.9 ± 4.8 ml kg-1 min-1 ) and CS (35.9 ± 2.4 vs. 31.9 ± 3.1 m min-1 , both P < 0.05). Local KATP channel inhibition decreased MG blood flow (52 ± 25 vs. 34 ± 13 ml min-1 100 g tissue-1 ) and PO2 isnadir (5.9 ± 0.9 vs. 4.7 ± 1.1 mmHg) during twitch contractions. Furthermore, MG V ̇ O2 was reduced via impaired Q ̇ O2 and DO2 (P < 0.05 for each). Collectively, these data support that vascular KATP channels help sustain submaximal exercise tolerance in healthy rats. For patients taking sulfonylureas, KATP channel inhibition may exacerbate exercise intolerance.
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Affiliation(s)
- Trenton D Colburn
- Department of Kinesiology, Kansas State University, Manhattan, KS, 66506, USA
| | - Ramona E Weber
- Department of Kinesiology, Kansas State University, Manhattan, KS, 66506, USA
| | - K Sue Hageman
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, 66506, USA
| | - Jacob T Caldwell
- Department of Kinesiology, Kansas State University, Manhattan, KS, 66506, USA
| | - Kiana M Schulze
- Department of Kinesiology, Kansas State University, Manhattan, KS, 66506, USA
| | - Carl J Ade
- Department of Kinesiology, Kansas State University, Manhattan, KS, 66506, USA
| | - Brad J Behnke
- Department of Kinesiology, Kansas State University, Manhattan, KS, 66506, USA
| | - David C Poole
- Department of Kinesiology, Kansas State University, Manhattan, KS, 66506, USA
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, 66506, USA
| | - Timothy I Musch
- Department of Kinesiology, Kansas State University, Manhattan, KS, 66506, USA
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, 66506, USA
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11
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Is metformin a geroprotector? A peek into the current clinical and experimental data. Mech Ageing Dev 2020; 191:111350. [DOI: 10.1016/j.mad.2020.111350] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/25/2020] [Accepted: 09/01/2020] [Indexed: 02/08/2023]
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12
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Takeda Y, Matoba K, Sekiguchi K, Nagai Y, Yokota T, Utsunomiya K, Nishimura R. Endothelial Dysfunction in Diabetes. Biomedicines 2020; 8:E182. [PMID: 32610588 PMCID: PMC7400447 DOI: 10.3390/biomedicines8070182] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/25/2020] [Accepted: 06/26/2020] [Indexed: 12/14/2022] Open
Abstract
Diabetes is a worldwide health issue closely associated with cardiovascular events. Given the pandemic of obesity, the identification of the basic underpinnings of vascular disease is strongly needed. Emerging evidence has suggested that endothelial dysfunction is a critical step in the progression of atherosclerosis. However, how diabetes affects the endothelium is poorly understood. Experimental and clinical studies have illuminated the tight link between insulin resistance and endothelial dysfunction. In addition, macrophage polarization from M2 towards M1 contributes to the process of endothelial damage. The possibility that novel classes of anti-hyperglycemic agents exert beneficial effects on the endothelial function and macrophage polarization has been raised. In this review, we discuss the current status of knowledge regarding the pathological significance of insulin signaling in endothelium. Finally, we summarize recent therapeutic strategies against endothelial dysfunction with an emphasis on macrophage polarity.
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Affiliation(s)
- Yusuke Takeda
- Division of Diabetes, Metabolism, and Endocrinology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (Y.T.); (K.S.); (Y.N.); (T.Y.); (R.N.)
| | - Keiichiro Matoba
- Division of Diabetes, Metabolism, and Endocrinology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (Y.T.); (K.S.); (Y.N.); (T.Y.); (R.N.)
| | - Kensuke Sekiguchi
- Division of Diabetes, Metabolism, and Endocrinology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (Y.T.); (K.S.); (Y.N.); (T.Y.); (R.N.)
| | - Yosuke Nagai
- Division of Diabetes, Metabolism, and Endocrinology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (Y.T.); (K.S.); (Y.N.); (T.Y.); (R.N.)
| | - Tamotsu Yokota
- Division of Diabetes, Metabolism, and Endocrinology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (Y.T.); (K.S.); (Y.N.); (T.Y.); (R.N.)
| | - Kazunori Utsunomiya
- Center for Preventive Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan;
| | - Rimei Nishimura
- Division of Diabetes, Metabolism, and Endocrinology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (Y.T.); (K.S.); (Y.N.); (T.Y.); (R.N.)
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Mehta A, Bhattacharya S, Estep J, Faiman C. Diabetes and Heart Failure: A Marriage of Inconvenience. Clin Geriatr Med 2020; 36:447-455. [PMID: 32586474 DOI: 10.1016/j.cger.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Type 2 diabetes and congestive heart failure are growing public health problems and are expected to worsen in the next decade. There is an inarguable link between diabetes and heart failure but only recently has there been an effort to elucidate the underlying pathophysiologic connection resulting in diabetic cardiomyopathy. Traditionally, diabetes and heart failure have been treated as 2 distinct disease entities, but recent advances in individual therapies have shown remarkable concomitant improvements in both diabetes and cardiovascular outcomes. This article aims to review the key connections in the epidemiology and etiopathophysiology of type 2 diabetes and heart failure.
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Affiliation(s)
- Adi Mehta
- Endocrinology and Metabolism Institute, Cleveland Clinic, 9500 Euclid Avenue, F-20, Cleveland, OH 44195, USA.
| | - Sanjeeb Bhattacharya
- Section of Heart Failure and Cardiac Transplant Medicine, Cleveland Clinic, 9500 Euclid Avenue, J3-4, Cleveland, OH 44195, USA. https://twitter.com/SBhattacharyaMD
| | - Jerry Estep
- Section of Heart Failure and Cardiac Transplant Medicine, Cleveland Clinic, 9500 Euclid Avenue, J3-4, Cleveland, OH 44195, USA
| | - Charles Faiman
- Department of Endocrinology, Cleveland Clinic, 9500 Euclid Avenue, F-20, Cleveland, OH 44195, USA
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14
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Xu Y, Wang T, Yang Z, Lin H, Shen P, Zhan S. Sulphonylureas monotherapy and risk of hospitalization for heart failure in patients with type 2 diabetes mellitus: A population-based cohort study in China. Pharmacoepidemiol Drug Saf 2020; 29:635-643. [PMID: 32383226 DOI: 10.1002/pds.5024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 12/19/2019] [Accepted: 04/19/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE The risk of heart failure associated with sulphonylureas is unclear. We evaluated the association between sulphonylureas and hospitalization of heart failure (HHF) in patients with type 2 diabetes mellitus (T2DM) in China. METHODS A retrospective cohort study was implemented using the Yinzhou Regional Health Care Database (YRHCD). We identified 15 752 adult patients with T2DM who were newly exposed to sulphonylurea monotherapy (N = 12 487) or acarbose monotherapy (N = 3265) from January 2010 to September 2016. Cox proportional hazards models weighted by inverse probability of treatment weights were used to compare the risk of HHF between initiators of sulphonylurea and acarbose. RESULTS During a median follow-up of 0.55 (0.49, 1.11) and 0.49 (0.35, 0.70) years for sulphonylureas and acarbose initiators separately, 320 patients developed HHF, with 279 events in sulphonylureas group, and 41 events in acarbose group. The incidence rates of HHF among sulphonylureas initiators and acarbose initiators were 22.2 (95% CI 19.6-24.9) and 18.3 (95% CI 13.2-24.9) per 1000 person-years, respectively. The adjusted hazard ratio (aHR) of HHF for sulphonylureas vs acarbose was 1.61 (95% CI 1.14-2.27). When stratified by history of heart failure, aHR was 1.55 (95% CI 0.79-3.06) in patients with a history of heart failure, and 1.64 (95% CI 1.10-2.45) in patients with no history of heart failure. CONCLUSIONS Our study suggested that use of sulphonylureas monotherapy compared with acarbose monotherapy for initial treatment of T2DM for approximately 0.5 years are significantly associated with a higher risk of HHF.
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Affiliation(s)
- Yang Xu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Tiansheng Wang
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Zhirong Yang
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Hongbo Lin
- Yinzhou District Center for Disease Control and Prevention, Ningbo, China
| | - Peng Shen
- Yinzhou District Center for Disease Control and Prevention, Ningbo, China
| | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
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15
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Effects of oral antidiabetic drugs and glucagon-like peptide-1 receptor agonists on left ventricular diastolic function in patients with type 2 diabetes mellitus: a systematic review and network meta-analysis. Heart Fail Rev 2020; 26:1151-1158. [PMID: 32080782 DOI: 10.1007/s10741-020-09936-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The present study aimed to compare the effects of oral antidiabetic drugs (OADs) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) on left ventricular diastolic function in patients with type 2 diabetes mellitus using a network meta-analysis of randomized controlled trials (RCTs). Literature searches were conducted on Medline, the Cochrane Controlled Trials Registry, and ClinicalTrials.gov . RCTs that assessed the effects on left ventricular diastolic function of OADs and GLP-1RAs in patients with type 2 diabetes were included. The outcome was the value (E/e') obtained by dividing peak early diastolic transmitral flow velocity (E) by the mitral annular early diastolic velocity (e'). Standardized mean differences (SMD) and 95% confidence intervals (CIs) were calculated from a random-effects network meta-analysis. Eight RCTs (592 patients) identified in a literature search met the eligibility criteria for this study and were included in the network meta-analysis. Compared with placebo, liraglutide was the only drug that caused a significant improvement in left ventricular diastolic function (SMD, - 0.65; 95% CI, - 1.23 to - 0.08). In addition, when the effects on left ventricular diastolic function were evaluated across drugs, liraglutide alone caused a significant improvement in left ventricular diastolic function compared with OADs (sitagliptin, linagliptin, pioglitazone, rosiglitazone, voglibose, and glimepiride). From the perspective of preventing the onset of heart failure, the administration of liraglutide for type 2 diabetes is promising.
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16
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Dong YH, Wang SV, Gagne JJ, Wu LC, Chang CH. Comparison of Different Case-Crossover Variants in Handling Exposure-Time Trend or Persistent-User Bias: Using Dipeptidyl Peptidase-4 Inhibitors and the Risk of Heart Failure as an Example. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:217-226. [PMID: 32113627 DOI: 10.1016/j.jval.2019.09.2746] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/19/2019] [Accepted: 09/14/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Inappropriate use of the case-crossover design, which is efficient for examining associations between brief exposure and abrupt outcomes, in evaluating the effects of medications in the presence of exposure-time trends or persistent drug use may generate spurious associations. We compared different approaches to adjusting for these sources of bias by examining the risk of heart failure hospitalization (HFH) associated with dipeptidyl peptidase-4 (DPP-4) inhibitors. Overall, existing evidence does not suggest a higher risk of HFH associated with DPP-4 inhibitors; however, case-crossover analyses of these medications may be susceptible to bias. METHODS We conducted case-crossover; age, sex, risk-set (ASR) matched case-time-control; disease risk score (DRS)-matched case-time-control; and case-case-time-control analyses to assess the association between DPP-4 inhibitors and HFH among patients with diabetes mellitus (DM) in a population-based Taiwanese database. We also examined metformin and sulfonylureas, both with assumed null associations. RESULTS Among 362 022 DM patients, 4105 (case-crossover), 4103 (ASR-matched case-time-control), 3957 (DRS-matched case-time-control), and 2812 (case-case-time-control) HFH cases were identified. The OR for DPP-4 inhibitors and HFH was elevated in the case-crossover analysis (1.52; 95% confidence interval [95% CI] 0.95-2.42). The ASR-matched case-time control, DRS-matched case-time-control, and case-case-time control analyses yielded near-null associations (0.90 [95% CI 0.45-1.83], 0.96 [95% CI 0.46-2.02], and 0.92 [95% CI 0.39-2.21], respectively). Null effects were observed for metformin across designs and for sulfonylureas in the case-case-time control analysis. CONCLUSIONS Our case-crossover analysis suggested DPP-4 inhibitors may be associated with HFH; however, each method for adjusting for exposure-time and persistent user bias attenuated the findings. The case-case-time-control analysis had the least precision.
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Affiliation(s)
- Yaa-Hui Dong
- School of Pharmaceutical Science, National Yang-Ming University, Taipei, Taiwan; Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Li-Chiu Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Hsuin Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Medicine, National Taiwan University, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
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Liu B, Wang Y, Zhang Y, Yan B. Mechanisms of Protective Effects of SGLT2 Inhibitors in Cardiovascular Disease and Renal Dysfunction. Curr Top Med Chem 2019; 19:1818-1849. [PMID: 31456521 DOI: 10.2174/1568026619666190828161409] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/09/2019] [Accepted: 07/25/2019] [Indexed: 02/07/2023]
Abstract
Type 2 diabetes mellitus is one of the most common forms of the disease worldwide. Hyperglycemia and insulin resistance play key roles in type 2 diabetes mellitus. Renal glucose reabsorption is an essential feature in glycaemic control. Kidneys filter 160 g of glucose daily in healthy subjects under euglycaemic conditions. The expanding epidemic of diabetes leads to a prevalence of diabetes-related cardiovascular disorders, in particular, heart failure and renal dysfunction. Cellular glucose uptake is a fundamental process for homeostasis, growth, and metabolism. In humans, three families of glucose transporters have been identified, including the glucose facilitators GLUTs, the sodium-glucose cotransporter SGLTs, and the recently identified SWEETs. Structures of the major isoforms of all three families were studied. Sodium-glucose cotransporter (SGLT2) provides most of the capacity for renal glucose reabsorption in the early proximal tubule. A number of cardiovascular outcome trials in patients with type 2 diabetes have been studied with SGLT2 inhibitors reducing cardiovascular morbidity and mortality. The current review article summarises these aspects and discusses possible mechanisms with SGLT2 inhibitors in protecting heart failure and renal dysfunction in diabetic patients. Through glucosuria, SGLT2 inhibitors reduce body weight and body fat, and shift substrate utilisation from carbohydrates to lipids and, possibly, ketone bodies. These pleiotropic effects of SGLT2 inhibitors are likely to have contributed to the results of the EMPA-REG OUTCOME trial in which the SGLT2 inhibitor, empagliflozin, slowed down the progression of chronic kidney disease and reduced major adverse cardiovascular events in high-risk individuals with type 2 diabetes. This review discusses the role of SGLT2 in the physiology and pathophysiology of renal glucose reabsorption and outlines the unexpected logic of inhibiting SGLT2 in the diabetic kidney.
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Affiliation(s)
- Ban Liu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuliang Wang
- Department of Immunology, Nanjing Medical University, Nanjing, China
| | - Yangyang Zhang
- Key Laboratory of Arrhythmias of the Ministry of Education of China, Tongji University School of Medicine, Shanghai, China.,Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Biao Yan
- Shanghai Key Laboratory of Visual Impairment and Restoration, Shanghai, China.,Eye Institute, Eye and ENT Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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18
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Tseng C. Metformin Use Is Associated With a Lower Risk of Hospitalization for Heart Failure in Patients With Type 2 Diabetes Mellitus: a Retrospective Cohort Analysis. J Am Heart Assoc 2019; 8:e011640. [PMID: 31630591 PMCID: PMC6898844 DOI: 10.1161/jaha.118.011640] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 09/10/2019] [Indexed: 12/19/2022]
Abstract
Background A beneficial effect of metformin on heart failure requires confirmation. Methods and Results Patients with new-onset type 2 diabetes mellitus during 1999 to 2005 were enrolled from Taiwan's National Health Insurance database and followed up from January 1, 2006, until December 31, 2011. Main analyses were conducted in an unmatched cohort (172 542 metformin ever users and 43 744 never users) and a propensity score matched-pair cohort (matched cohort I, 41 714 ever users and 41 714 never users). Hazard ratios were estimated by Cox hazard regression incorporated with the inverse probability of treatment weighting using the propensity score in the unmatched cohort and by naïve method in the matched cohort I. Results showed that the respective incidence rates of heart failure hospitalization in ever users and never users were 304.25 and 864.31 per 100 000 person-years in the unmatched cohort (hazard ratio, 0.350; 95% CI, 0.329-0.373) and were 469.66 and 817.01 per 100 000 person-years in the matched cohort I (hazard ratio, 0.571; 95% CI, 0.526-0.620). A dose-response pattern was consistently observed while estimating hazard ratios for the tertiles of cumulative duration of metformin therapy. Findings were supported by another propensity score-matched cohort created after excluding 10 potential instrumental variables in the estimation of propensity score (matched cohort II). An approximately 40% lower risk was consistently observed among ever users in different models derived from the matched cohorts I and II, but models from the matched cohort II were less subject to model misspecification. Conclusions Metformin use is associated with a lower risk of heart failure hospitalization.
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Affiliation(s)
- Chin‐Hsiao Tseng
- Department of Internal MedicineNational Taiwan University College of MedicineTaipeiTaiwan
- Division of Endocrinology and MetabolismDepartment of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
- Division of Environmental Health and Occupational MedicineNational Health Research InstitutesZhunanTaiwan
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Komamine M, Kajiyama K, Ishiguro C, Uyama Y. Cardiovascular risks associated with dipeptidyl peptidase‐4 inhibitors monotherapy compared with other antidiabetes drugs in the Japanese population: A nationwide cohort study. Pharmacoepidemiol Drug Saf 2019; 28:1166-1174. [DOI: 10.1002/pds.4847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 04/15/2019] [Accepted: 06/02/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Maki Komamine
- Office of Medical Informatics and EpidemiologyPharmaceuticals and Medical Devices Agency Tokyo Japan
| | - Kazuhiro Kajiyama
- Office of Medical Informatics and EpidemiologyPharmaceuticals and Medical Devices Agency Tokyo Japan
| | - Chieko Ishiguro
- Office of Medical Informatics and EpidemiologyPharmaceuticals and Medical Devices Agency Tokyo Japan
| | - Yoshiaki Uyama
- Office of Medical Informatics and EpidemiologyPharmaceuticals and Medical Devices Agency Tokyo Japan
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20
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Woo V, Connelly K, Lin P, McFarlane P. The role of sodium glucose cotransporter-2 (SGLT-2) inhibitors in heart failure and chronic kidney disease in type 2 diabetes. Curr Med Res Opin 2019; 35:1283-1295. [PMID: 30767677 DOI: 10.1080/03007995.2019.1576479] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: Heart failure (HF) and chronic kidney disease (CKD) are responsible for substantial morbidity and mortality in individuals with type 2 diabetes (T2D). Methods: This review discusses the significance of these comorbidities of T2D and current options for managing them, with a focus on sodium-glucose cotransporter-2 (SGLT-2) inhibitors. Based on a focused literature search of cardiovascular outcomes trials (CVOTs), this review assessed the effects of SGLT-2 inhibitors in individuals with T2D with or without established cardiovascular disease (CVD). Results: In addition to effective glycemic control and weight loss, SGLT-2 inhibitor treatment of T2D prevents adverse cardiovascular and renal outcomes in individuals with and without these comorbidities. Reduced rate of hospitalization due to HF (HHF) and improved renal outcomes appear to be class effects of SGLT-2 inhibitors. Reduction in CV events may be more significant in individuals with established cardiovascular disease. Conclusions: CVOTs and other studies confirm that the SGLT-2 inhibitors, mostly used in combination with other glucose-lowering drugs, offer several clinical benefits beyond improved glycemic control. These include reducing HHF risk and improving renal outcomes. HF and renal benefits are observed in individuals with and without established CVD, which may simplify therapeutic selection. Ongoing SGLT-2 inhibitor CVOTs will help clarify the potential of these drugs to treat T2D comorbid with different forms of HF (HF with preserved vs reduced ejection fraction) and different degrees of renal dysfunction, and in individuals with T2D vs pre-diabetes or normal glucose metabolism.
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Affiliation(s)
- Vincent Woo
- a Section of Endocrinology John Buhler Research Centre, University of Manitoba , Winnipeg , Manitoba , Canada
| | - Kim Connelly
- b Department of Medicine, Division of Cardiology , St Michael's Hospital, University of Toronto , Toronto , Ontario , Canada
- c St. Michael's Hospital , Keenan Research Centre for Biomedical Science , Toronto , Ontario , Canada
| | - Peter Lin
- d Primary Care Initiatives, Canadian Heart Research Centre , Toronto , Ontario , Canada
| | - Philip McFarlane
- e Division of Nephrology , St. Michael's Hospital , Toronto , Ontario , Canada
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Dunlay SM, Givertz MM, Aguilar D, Allen LA, Chan M, Desai AS, Deswal A, Dickson VV, Kosiborod MN, Lekavich CL, McCoy RG, Mentz RJ, Piña IL. Type 2 Diabetes Mellitus and Heart Failure: A Scientific Statement From the American Heart Association and the Heart Failure Society of America: This statement does not represent an update of the 2017 ACC/AHA/HFSA heart failure guideline update. Circulation 2019; 140:e294-e324. [PMID: 31167558 DOI: 10.1161/cir.0000000000000691] [Citation(s) in RCA: 314] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.
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Dunlay SM, Givertz MM, Aguilar D, Allen LA, Chan M, Desai AS, Deswal A, Dickson VV, Kosiborod MN, Lekavich CL, McCoy RG, Mentz RJ, PiÑa IL. Type 2 Diabetes Mellitus and Heart Failure, A Scientific Statement From the American Heart Association and Heart Failure Society of America. J Card Fail 2019; 25:584-619. [PMID: 31174952 DOI: 10.1016/j.cardfail.2019.05.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus is a risk factor for incident heart failure and increases the risk of morbidity and mortality in patients with established disease. Secular trends in the prevalence of diabetes mellitus and heart failure forecast a growing burden of disease and underscore the need for effective therapeutic strategies. Recent clinical trials have demonstrated the shared pathophysiology between diabetes mellitus and heart failure, the synergistic effect of managing both conditions, and the potential for diabetes mellitus therapies to modulate the risk of heart failure outcomes. This scientific statement on diabetes mellitus and heart failure summarizes the epidemiology, pathophysiology, and impact of diabetes mellitus and its control on outcomes in heart failure; reviews the approach to pharmacological therapy and lifestyle modification in patients with diabetes mellitus and heart failure; highlights the value of multidisciplinary interventions to improve clinical outcomes in this population; and outlines priorities for future research.
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23
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Bell DSH, Goncalves E. Heart failure in the patient with diabetes: Epidemiology, aetiology, prognosis, therapy and the effect of glucose-lowering medications. Diabetes Obes Metab 2019; 21:1277-1290. [PMID: 30724013 DOI: 10.1111/dom.13652] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 01/29/2019] [Accepted: 02/03/2019] [Indexed: 12/24/2022]
Abstract
In people with type 2 diabetes the frequency of heart failure (HF) is increased and mortality from HF is higher than with non-diabetic HF. The increased frequency of HF is attributable to the cardiotoxic tetrad of ischaemic heart disease, left ventricular hypertrophy, diabetic cardiomyopathy and an extracellular volume expansion resistant to atrial natriuretic peptides. Activation of the renin-angiotensin-aldosterone system and sympathetic nervous systems results in cardiac remodelling, which worsens cardiac function. Reversal of remodelling can be achieved, and cardiac function improved in people with HF with reduced ejection fraction (HFrEF) by treatment with angiotensin-converting enzyme inhibitors and β-blockers. However, with HF with preserved ejection fraction (HFpEF), only therapy for the underlying risk factors helps. Blockers of mineralocorticoid receptors may be beneficial in both HFrEF and HFpEF. Glucose-lowering drugs can have a negative effect (insulin, sulphonylureas, dipeptidyl peptidase-4 inhibitors and thiazolidinediones), a neutral effect (α-glucosidase inhibitors and glucagon-like peptide-1 receptor agonists) or a positive effect (sodium-glucose co-transporter-2 inhibitors and metformin).
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24
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Packer M. Is the Way to Someone's Heart Through Their Stomach? The Cardiorenal Paradox of Incretin-Based Hypoglycemic Drugs in Heart Failure. Circ Heart Fail 2019; 10:CIRCHEARTFAILURE.117.004551. [PMID: 29021350 DOI: 10.1161/circheartfailure.117.004551] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Milton Packer
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX.
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25
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Asleh R, Sheikh-Ahmad M, Briasoulis A, Kushwaha SS. The influence of anti-hyperglycemic drug therapy on cardiovascular and heart failure outcomes in patients with type 2 diabetes mellitus. Heart Fail Rev 2019; 23:445-459. [PMID: 29270818 DOI: 10.1007/s10741-017-9666-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patients with type 2 diabetes mellitus (DM) are at a substantially increased risk of heart failure (HF) and HF mortality. Despite the lack of evidence that tight glycemic control reduces the incidence of cardiovascular (CV) events, a growing body of evidence suggests that the choice of glucose-lowering agents may influence outcomes including HF. Thiazolidinediones are associated with a significant risk of HF. For metformin, sulphonylureas and insulin, little data is available to indicate the impact on HF. The glucagon-like peptide-1 (GLP-1) agonists, liraglutide and semaglutide, have been shown to reduce major CV events, but did not affect rates of hospitalization for HF. Clinical trials have demonstrated diverse effects of Dipeptidyl peptidase-4 (DPP-4) inhibitors on HF; saxagliptin showed an increased risk of HF admissions, alogliptin was associated with higher rates of new HF admissions, while sitagliptin had a neutral effect. The sodium-glucose cotransporter 2 (SGLT2) inhibitors, empagliflozin and canagliflozin, have been recently shown to reduce the incidence of HF and cardiovascular mortality in patients with and without a history of HF. This review will summarize key findings of the impact of glucose-lowering agents on CV safety and HF-associated outcomes, present available data on the underlying mechanisms for the benefits of the SGLT2 inhibitors on HF, and discuss strategies to improve outcomes in patients with DM and high CV risk.
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Affiliation(s)
- Rabea Asleh
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St. SW, Gonda 5 S, Rochester, MN, 55905, USA.
| | | | - Alexandros Briasoulis
- Department of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St. SW, Gonda 5 S, Rochester, MN, 55905, USA
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26
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Shah SR, Iqbal SM, Alweis R, Roark S. A closer look at heart failure in patients with concurrent diabetes mellitus using glucose lowering drugs. Expert Rev Clin Pharmacol 2018; 12:45-52. [PMID: 30488734 DOI: 10.1080/17512433.2019.1552830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Type 2 diabetes (T2D) is an independent risk factor for heart failure (HF). With concomitant T2D and HF, recent data suggests an incremental risk of cardiovascular death and hospitalization for HF, as compared to patients with HF without T2D. Areas covered: Management of these two diseases has been a challenge for physicians. The treatment goals for HF patients in T2D are very important. They serve as the endpoint in using a specific treatment for management and treatment of T2D patients hence, decreasing mortality rates. In this review, we examine the effects of oral antidiabetic drugs on HF patients, discussing current evidence-based up-to-date management strategies and guidelines in the general population with HF and T2D. Expert commentary: Future in the management of T2D in HF patients looks bright. Augmenting data on potential cardiovascular side effects of antidiabetic drugs is valuable since millions of people are treated over many years. Newer novel drugs targeting specific signaling pathways are approaching the stages of clinical investigation. They have been a highly attractive concept for the future in the management of these patients. However, while advances in technology elucidated many aspects of these diseases, many mysteries still remain.
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Affiliation(s)
- Syed Raza Shah
- a North Florida Regional Medical Center , University of Central Florida (Gainesville) , Gainesville , FL , USA
| | - Sana Muhammad Iqbal
- b Department of Medicine , Dow University of Health Sciences (DUHS) , Karachi , Pakistan
| | - Richard Alweis
- c Department of Medicine , Rochester Regional Health System , Rochester , NY , USA
| | - Steven Roark
- d North Florida Regional Medical Center, The Cardiac and Vascular Institute , University of Central Florida (Gainesville) , Gainesville , FL , USA
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27
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Packer M. Are physicians neglecting the risk of heart failure in diabetic patients who are receiving sulfonylureas? Lessons from the TOSCA.IT trial. Eur J Heart Fail 2018; 20:49-51. [PMID: 29388338 DOI: 10.1002/ejhf.1093] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 10/30/2017] [Accepted: 11/02/2017] [Indexed: 02/06/2023] Open
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
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28
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Dziubak A, Wójcicka G, Wojtak A, Bełtowski J. Metabolic Effects of Metformin in the Failing Heart. Int J Mol Sci 2018; 19:ijms19102869. [PMID: 30248910 PMCID: PMC6213955 DOI: 10.3390/ijms19102869] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/11/2018] [Accepted: 09/17/2018] [Indexed: 01/03/2023] Open
Abstract
Accumulating evidence shows that metformin is an insulin-sensitizing antidiabetic drug widely used in the treatment of type 2 diabetes mellitus (T2DM), which can exert favorable effects on cardiovascular risk and may be safely used in patients with heart failure (HF), and even able to reduce the incidence of HF and to reduce HF mortality. In failing hearts, metformin improves myocardial energy metabolic status through the activation of AMP (adenosine monophosphate)-activated protein kinase (AMPK) and the regulation of lipid and glucose metabolism. By increasing nitric oxide (NO) bioavailability, limiting interstitial fibrosis, reducing the deposition of advanced glycation end-products (AGEs), and inhibiting myocardial cell apoptosis metformin reduces cardiac remodeling and hypertrophy, and thereby preserves left ventricular systolic and diastolic functions. While a lot of preclinical and clinical studies showed the cardiovascular safety of metformin therapy in diabetic patients and HF, to confirm observed benefits, the specific large-scale trials configured for HF development in diabetic patients as a primary endpoints are necessary.
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Affiliation(s)
- Aleksandra Dziubak
- Department of Pathophysiology, Medical University of Lublin, ul. Jaczewskiego 8b, 20-090 Lublin, Poland.
| | - Grażyna Wójcicka
- Department of Pathophysiology, Medical University of Lublin, ul. Jaczewskiego 8b, 20-090 Lublin, Poland.
| | - Andrzej Wojtak
- Department of Vascular Surgery, Medical University of Lubin, 20-090 Lublin, Poland.
| | - Jerzy Bełtowski
- Department of Pathophysiology, Medical University of Lublin, ul. Jaczewskiego 8b, 20-090 Lublin, Poland.
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29
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Al-Badri A, Hashmath Z, Oldland GH, Miller R, Javaid K, Syed AA, Ansari B, Gaddam S, Witschey WR, Akers SR, Chirinos JA. Poor Glycemic Control Is Associated With Increased Extracellular Volume Fraction in Diabetes. Diabetes Care 2018; 41:2019-2025. [PMID: 30002196 PMCID: PMC6105326 DOI: 10.2337/dc18-0324] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/18/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We assessed whether poor glycemic control is associated with an increase in myocardial fibrosis among adults with diabetes. RESEARCH DESIGN AND METHODS We studied 47 adults with type 2 diabetes and stratified them into three groups according to their hemoglobin A1c (HbA1c) level: <6.5% (group 1; n = 12), 6.5-7.5% (group 2; n = 20), and >7.5% (group 3; n = 15). Left ventricular (LV) mass was assessed using cardiac MRI. The extracellular volume fraction (ECVF), an index of myocardial fibrosis, was measured by using myocardial T1 mapping before and after the administration of a gadolinium-based contrast agent. RESULTS Mean HbA1c was 5.84 ± 0.16%, 6.89 ± 0.14%, and 8.57 ± 0.2% in groups 1, 2, and 3, respectively. LV mass was not significantly different between the groups. The myocardial ECVF was significantly greater in groups 2 (mean 27.6% [95% CI 24.8-30.3]) and 3 (27.6% [24.4-30.8]) than in group 1 (21.1% [17.5-24.7]; P = 0.015). After adjusting for age, sex, BMI, blood pressure, and estimated glomerular filtration rate, the myocardial ECVF was significantly greater in groups 2 (27.4% [24.4-30.4]) and 3 (28% [24.5-31.5]) than in group 1 (20.9% [17.1-24.6]; P = 0.0156, ANCOVA). CONCLUSIONS An increased myocardial ECVF, suggesting myocardial fibrosis, is independently associated with poor glycemic control among adults with diabetes. Further research should assess whether tight glycemic control can revert fibrosis to healthy myocardium or ameliorate it and its adverse clinical consequences.
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Affiliation(s)
| | - Zeba Hashmath
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Garrett H Oldland
- Hospital of the University of Pennsylvania, Philadelphia, PA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Rachana Miller
- Hospital of the University of Pennsylvania, Philadelphia, PA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Khuzaima Javaid
- Hospital of the University of Pennsylvania, Philadelphia, PA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Amer Ahmed Syed
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Bilal Ansari
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Swetha Gaddam
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Walter R Witschey
- Hospital of the University of Pennsylvania, Philadelphia, PA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Scott R Akers
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Julio A Chirinos
- Hospital of the University of Pennsylvania, Philadelphia, PA .,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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30
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Packer M. Have we really demonstrated the cardiovascular safety of anti-hyperglycaemic drugs? Rethinking the concepts of macrovascular and microvascular disease in type 2 diabetes. Diabetes Obes Metab 2018; 20:1089-1095. [PMID: 29316137 DOI: 10.1111/dom.13207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 12/12/2017] [Accepted: 12/22/2017] [Indexed: 02/06/2023]
Abstract
A primary goal of the treatment of type 2 mellitus is the prevention of morbidity and mortality associated with cardiovascular disease; however, anti-hyperglycaemic drugs have the capacity to cause deleterious effects on the circulation, a risk that is not adequately reflected by the endpoints selected for emphasis in large-scale clinical trials that are designed to evaluate cardiovascular safety. The primary endpoint of the large-scale studies mandated by regulatory authorities focuses only on 3 to 4 events that depict only a limited view of the circulatory system. One of the most serious adverse effects of many glucose-lowering drugs is new-onset or worsening heart failure. Most antidiabetic drugs can aggravate heart failure because they exert anti-natriuretic actions, and possibly, adverse effects on the myocardium. In addition, certain anti-hyperglycaemic agents may worsen peripheral vascular disease and trigger cardiac arrhythmias that may lead to sudden death. Initiation of treatment with antidiabetic medications may also cause deterioration of the function of the kidneys, retina and peripheral nerves, which are typically regarded as reflecting microvascular disease. The current confusion about the cardiovascular effects of glucose-lowering drugs may be exacerbated by conceptual uncertainties about the classification of large and small vessel disease in determining the clinical course of diabetes. Physicians should not be falsely reassured by claims that a new treatment appears to have passed a narrowly defined regulatory test. The management of people with diabetes often carries with it the risk of important cardiovascular consequences, even for drugs that do not overtly increase the risk of myocardial infarction or stroke.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
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31
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Ofstad AP, Atar D, Gullestad L, Langslet G, Johansen OE. The heart failure burden of type 2 diabetes mellitus-a review of pathophysiology and interventions. Heart Fail Rev 2018; 23:303-323. [PMID: 29516230 PMCID: PMC5937871 DOI: 10.1007/s10741-018-9685-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetes and heart failure (HF) are both global epidemics with tremendous costs on society with increased rates of HF hospitalizations and worsened prognosis when co-existing, making it a significant "deadly duo." The evidence for pharmacological treatment of HF in patients with type 2 diabetes mellitus (T2DM) stems typically from either subgroup analyses of patients that were recruited to randomized controlled trials of HF interventions, usually in patients with reduced ejection fraction (EF), or from subgroup analyses of HF patients recruited to cardiovascular (CV) outcome trials (CVOT) of glucose lowering agents involving patients with T2DM. Studies in patients with HF with preserved EF are sparse. This review summarizes the literature on pathophysiology and interventions aiming to reduce the HF burden in T2DM and includes HF trials of ACEi, digoxin, β-blocker, ARB, If-blocker, MRA, and ARNI involving 38,600 patients, with or without prevalent diabetes, and CV outcome trials in T2DM involving 74,351 patients, with or without prevalent HF. In all HF trials, HF outcomes by prevalent diabetes were reported with an incremental risk of HF and death confessed by prevalent diabetes and a treatment effect similar to those without diabetes. All T2DM CVOTs reported on HF outcomes with heterogeneity between trials with two reporting benefits (empagliflozin and canagliflozin) and two reporting increased risk (saxagliptin, pioglitazone). In vulnerable T2DM patients with concomitant HF, guideline-recommended HF drugs are effective. When choosing glucose-lowering therapy, outcomes from available CVOTs should be considered.
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Affiliation(s)
- Anne Pernille Ofstad
- Bærum Hospital, Vestre Viken HF, Rud, Norway.
- Medical Department, Boehringer Ingelheim, Asker, Norway.
| | - Dan Atar
- Department of Cardiology B, Oslo University Hospital, Ullevål, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lars Gullestad
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Gisle Langslet
- Rikshospitalet, Lipid Clinic, Oslo University Hospital, Oslo, Norway
| | - Odd Erik Johansen
- Bærum Hospital, Vestre Viken HF, Rud, Norway
- Medical Department, Boehringer Ingelheim, Asker, Norway
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32
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Campbell JM, Bellman SM, Stephenson MD, Lisy K. Metformin reduces all-cause mortality and diseases of ageing independent of its effect on diabetes control: A systematic review and meta-analysis. Ageing Res Rev 2017; 40:31-44. [PMID: 28802803 DOI: 10.1016/j.arr.2017.08.003] [Citation(s) in RCA: 266] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 12/19/2022]
Abstract
This systematic review investigated whether the insulin sensitiser metformin has a geroprotective effect in humans. Pubmed and Embase were searched along with databases of unpublished studies. Eligible research investigated the effect of metformin on all-cause mortality or diseases of ageing relative to non-diabetic populations or diabetics receiving other therapies with adjustment for disease control achieved. Overall, 260 full-texts were reviewed and 53 met the inclusion criteria. Diabetics taking metformin had significantly lower all-cause mortality than non-diabetics (hazard ratio (HR)=0.93, 95%CI 0.88-0.99), as did diabetics taking metformin compared to diabetics receiving non-metformin therapies (HR=0.72, 95%CI 0.65-0.80), insulin (HR=0.68, 95%CI 0.63-0.75) or sulphonylurea (HR=0.80, 95%CI 0.66-0.97). Metformin users also had reduced cancer compared to non-diabetics (rate ratio=0.94, 95%CI 0.92-0.97) and cardiovascular disease (CVD) compared to diabetics receiving non-metformin therapies (HR=0.76, 95%CI 0.66-0.87) or insulin (HR=0.78, 95%CI 0.73-0.83). Differences in baseline characteristics were observed which had the potential to bias findings, although statistical adjustments were made. The apparent reductions in all-cause mortality and diseases of ageing associated with metformin use suggest that metformin could be extending life and healthspans by acting as a geroprotective agent.
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Affiliation(s)
- Jared M Campbell
- The Joanna Briggs Institute, The University of Adelaide, Adelaide, South Australia, Australia; Centre for Nanoscale BioPhotonics, Macquarie University, Sydney, New South Wales, Australia.
| | - Susan M Bellman
- The Joanna Briggs Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Matthew D Stephenson
- The Joanna Briggs Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Karolina Lisy
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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33
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Kim YG, Yoon D, Park S, Han SJ, Kim DJ, Lee KW, Park RW, Kim HJ. Dipeptidyl Peptidase-4 Inhibitors and Risk of Heart Failure in Patients With Type 2 Diabetes Mellitus: A Population-Based Cohort Study. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.003957. [PMID: 28899989 DOI: 10.1161/circheartfailure.117.003957] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 08/15/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND The association between dipeptidyl-peptidase IV inhibitors (DPP-4i) and heart failure (HF) remains unclear. In 1 randomized controlled trial and some observational studies, DPP-4i reportedly increased the risk of HF, but 2 other randomized controlled trials and observational studies have shown no such risk. Here, we evaluated the risk of HF and cardiovascular outcomes of DPP-4i compared with sulfonylureas. METHODS AND RESULTS A population-based retrospective cohort study was conducted using the Korean Health Insurance Review and Assessment Service database from January 1, 2009, to December 31, 2015. Incident users of sulfonylurea and DPP-4i who were not prescribed the comparator drug in the year before treatment initiation were included. DPP-4i-treated and sulfonylurea-treated patients were matched on propensity score, calculated with >40 variables. The risk of hospitalization for HF was evaluated with a Cox proportional hazards model in 255 691 matched pairs. Analyses were conducted in the total patient population and in both strata divided by the presence of cardiovascular disease during the baseline period. The hazard ratios (HRs) of hospitalization for HF for DPP-4i-treated patients were 0.78 (95% confidence interval [CI], 0.67-0.86) in all of the patients, 0.77 (95% CI, 0.68-0.79) in patients with baseline cardiovascular disease, and 0.71 (95% CI, 0.56-0.90) in patients without baseline cardiovascular disease compared with HRs for sulfonylurea-treated patients. Sitagliptin and linagliptin showed statistically lower risk for hospitalization for HF (HR, 0.76; 95% CI, 0.67-0.86 for sitagliptin-prescribed patients; HR, 0.74; 95% CI, 0.59-0.92 for linagliptin-prescribed patients) than for sulfonylurea. The HRs for hospitalization for myocardial infarction and stroke with the use of a DPP-4i versus sulfonylurea were HR, 0.76 (95% CI, 0.67-0.87) and HR, 0.63 (95% CI, 0.60-0.67), respectively. CONCLUSIONS Our findings suggest that DPP-4i use did not increase the risk of HF compared with sulfonylurea. In addition, the risks for cardiovascular outcomes were not elevated in DPP-4i-treated patients compared with sulfonylurea-treated patients.
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Affiliation(s)
- Young-Gun Kim
- From the Department of Biomedical Informatics (Y.-G.K., D.Y., S.P., R.W.P.), Department of Endocrinology and Metabolism (S.J.H., D.J.K., K.-W. L., H.J.K.), and Department of Biomedical Sciences (R.W.P.), Ajou University School of Medicine, Suwon, South Korea; and Department of Statistics, Ewha Womans University, Seoul, South Korea (S.P.)
| | - Dukyong Yoon
- From the Department of Biomedical Informatics (Y.-G.K., D.Y., S.P., R.W.P.), Department of Endocrinology and Metabolism (S.J.H., D.J.K., K.-W. L., H.J.K.), and Department of Biomedical Sciences (R.W.P.), Ajou University School of Medicine, Suwon, South Korea; and Department of Statistics, Ewha Womans University, Seoul, South Korea (S.P.)
| | - Sooyoung Park
- From the Department of Biomedical Informatics (Y.-G.K., D.Y., S.P., R.W.P.), Department of Endocrinology and Metabolism (S.J.H., D.J.K., K.-W. L., H.J.K.), and Department of Biomedical Sciences (R.W.P.), Ajou University School of Medicine, Suwon, South Korea; and Department of Statistics, Ewha Womans University, Seoul, South Korea (S.P.)
| | - Seung Jin Han
- From the Department of Biomedical Informatics (Y.-G.K., D.Y., S.P., R.W.P.), Department of Endocrinology and Metabolism (S.J.H., D.J.K., K.-W. L., H.J.K.), and Department of Biomedical Sciences (R.W.P.), Ajou University School of Medicine, Suwon, South Korea; and Department of Statistics, Ewha Womans University, Seoul, South Korea (S.P.)
| | - Dae Jung Kim
- From the Department of Biomedical Informatics (Y.-G.K., D.Y., S.P., R.W.P.), Department of Endocrinology and Metabolism (S.J.H., D.J.K., K.-W. L., H.J.K.), and Department of Biomedical Sciences (R.W.P.), Ajou University School of Medicine, Suwon, South Korea; and Department of Statistics, Ewha Womans University, Seoul, South Korea (S.P.)
| | - Kwan-Woo Lee
- From the Department of Biomedical Informatics (Y.-G.K., D.Y., S.P., R.W.P.), Department of Endocrinology and Metabolism (S.J.H., D.J.K., K.-W. L., H.J.K.), and Department of Biomedical Sciences (R.W.P.), Ajou University School of Medicine, Suwon, South Korea; and Department of Statistics, Ewha Womans University, Seoul, South Korea (S.P.)
| | - Rae Woong Park
- From the Department of Biomedical Informatics (Y.-G.K., D.Y., S.P., R.W.P.), Department of Endocrinology and Metabolism (S.J.H., D.J.K., K.-W. L., H.J.K.), and Department of Biomedical Sciences (R.W.P.), Ajou University School of Medicine, Suwon, South Korea; and Department of Statistics, Ewha Womans University, Seoul, South Korea (S.P.).
| | - Hae Jin Kim
- From the Department of Biomedical Informatics (Y.-G.K., D.Y., S.P., R.W.P.), Department of Endocrinology and Metabolism (S.J.H., D.J.K., K.-W. L., H.J.K.), and Department of Biomedical Sciences (R.W.P.), Ajou University School of Medicine, Suwon, South Korea; and Department of Statistics, Ewha Womans University, Seoul, South Korea (S.P.).
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34
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Butler J, Hamo CE, Filippatos G, Pocock SJ, Bernstein RA, Brueckmann M, Cheung AK, George JT, Green JB, Januzzi JL, Kaul S, Lam CSP, Lip GYH, Marx N, McCullough PA, Mehta CR, Ponikowski P, Rosenstock J, Sattar N, Salsali A, Scirica BM, Shah SJ, Tsutsui H, Verma S, Wanner C, Woerle HJ, Zannad F, Anker SD. The potential role and rationale for treatment of heart failure with sodium-glucose co-transporter 2 inhibitors. Eur J Heart Fail 2017; 19:1390-1400. [PMID: 28836359 DOI: 10.1002/ejhf.933] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/27/2017] [Accepted: 06/05/2017] [Indexed: 12/28/2022] Open
Abstract
Heart failure (HF) and type 2 diabetes mellitus (T2DM) are both growing public health concerns contributing to major medical and economic burdens to society. T2DM increases the risk of HF, frequently occurs concomitantly with HF, and worsens the prognosis of HF. Several anti-hyperglycaemic medications have been associated with a concern for worse HF outcomes. More recently, the results of the EMPA-REG OUTCOME trial showed that the sodium-glucose co-transporter 2 (SGLT2) inhibitor empagliflozin was associated with a pronounced and precocious 38% reduction in cardiovascular mortality in subjects with T2DM and established cardiovascular disease [Correction added on 8 September 2017, after first online publication: "32%" in the previous sentence was corrected to "38%"]. These benefits were more related to a reduction in incident HF events rather than to ischaemic vascular endpoints. Several mechanisms have been put forward to explain these benefits, which also raise the possibility of using these drugs as therapies not only in the prevention of HF, but also for the treatment of patients with established HF regardless of the presence or absence of diabetes. Several large trials are currently exploring this postulate.
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Affiliation(s)
- Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, NY, USA
| | - Carine E Hamo
- Cardiology Division, Stony Brook University, Stony Brook, NY, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard A Bernstein
- Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA
| | - Martina Brueckmann
- Boehringer Ingelheim Pharmaceuticals Inc., Ingelheim, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, UT, USA
| | - Jyothis T George
- Boehringer Ingelheim Pharmaceuticals Inc., Ingelheim, Germany.,Warwick Medical School, University of Warwick, UK
| | - Jennifer B Green
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sanjay Kaul
- Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Gregory Y H Lip
- Institute of Cardiovascular Science, University of Birmingham, UK, and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Nikolaus Marx
- Department of Internal Medicine I, Cardiology, RWTH Aachen University, Aachen, Germany
| | | | | | | | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Naveed Sattar
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Benjamin M Scirica
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sanjiv J Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital Departments of Surgery, and Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital, Wurzburg, Germany
| | | | - Faiez Zannad
- Inserm CIC 1433, U 1116, Université de Lorraine and CHU, Nancy, France
| | - Stefan D Anker
- Department of Cardiology and Pneumology, University Medical Centre Göttingen, Göttingen, Germany.,Division of Cardiology and Metabolism, Department of Cardiology (CVK).,Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK) Berlin, Germany.,Charité Universitätsmedizin Berlin, Germany
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Sharma DC, Asirvatham A, Singh P. Dose Modification of Antidiabetic Agents in Patients with Type 2 Diabetes Mellitus and Heart Failure. Indian J Endocrinol Metab 2017; 21:618-629. [PMID: 28670548 PMCID: PMC5477452 DOI: 10.4103/ijem.ijem_442_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Heart failure is the most common comorbidity of diabetes. The incidence of heart failure in patients with diabetes is about 9%-22%, which is four times higher Than that in patients without diabetes. Heart failure and diabetes are collectively associated with increased morbidity and mortality compared to either condition alone. Several epidemiological studies have demonstrated an increased risk of heart failure in patients with diabetes; moreover, poor glycemic control accounts for the increased risk of heart failure. At present, several oral (metformin, sulfonylureas, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, etc.) as well as injectable (insulins, glucagon-like peptide 1 receptor agonists) antidiabetic agents are available. However, optimal treatment strategy to achieve adequate glycemic control in patients with type 2 diabetes mellitus (T2DM) and heart failure has not been well studied. In the view of rising prevalence of heart failure in patients with diabetes mellitus, clinicians need to understand the potential implications of antidiabetic agents in patients with heart failure. A group of experts from across India were involved in a consensus meeting in Pondicherry during the National Insulin Summit in November 2015. They evaluated agents currently available for the treatment of diabetes looking at existing scientific evidence relevant to each class of therapy. In addition, the existing guidelines and prescribing literature available with all these agents were also reviewed. Findings from the expert evaluations were then factored into the national context incorporating personal experience and common clinical practices in India. The purpose of this consensus document is to assist the clinicians while treating patients with T2DM and heart failure.
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Affiliation(s)
- D. C. Sharma
- Department of Endocrinology, RNT Medical College, Udaipur, Rajasthan, India
| | | | - Parminder Singh
- Division of Endocrinology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
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Azoulay L, Suissa S. Sulfonylureas and the Risks of Cardiovascular Events and Death: A Methodological Meta-Regression Analysis of the Observational Studies. Diabetes Care 2017; 40:706-714. [PMID: 28428321 DOI: 10.2337/dc16-1943] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 01/07/2017] [Indexed: 02/03/2023]
Abstract
Recent randomized trials have compared the newer antidiabetic agents to treatments involving sulfonylureas, drugs associated with increased cardiovascular risks and mortality in some observational studies with conflicting results. We reviewed the methodology of these observational studies by searching MEDLINE from inception to December 2015 for all studies of the association between sulfonylureas and cardiovascular events or mortality. Each study was appraised with respect to the comparator, the outcome, and study design-related sources of bias. A meta-regression analysis was used to evaluate heterogeneity. A total of 19 studies were identified, of which six had no major design-related biases. Sulfonylureas were associated with an increased risk of cardiovascular events and mortality in five of these studies (relative risks 1.16-1.55). Overall, the 19 studies resulted in 36 relative risks as some studies assessed multiple outcomes or comparators. Of the 36 analyses, metformin was the comparator in 27 (75%) and death was the outcome in 24 (67%). The relative risk was higher by 13% when the comparator was metformin, by 20% when death was the outcome, and by 7% when the studies had design-related biases. The lowest predicted relative risk was for studies with no major bias, comparator other than metformin, and cardiovascular outcome (1.06 [95% CI 0.92-1.23]), whereas the highest was for studies with bias, metformin comparator, and mortality outcome (1.53 [95% CI 1.43-1.65]). In summary, sulfonylureas were associated with an increased risk of cardiovascular events and mortality in the majority of studies with no major design-related biases. Among studies with important biases, the association varied significantly with respect to the comparator, the outcome, and the type of bias. With the introduction of new antidiabetic drugs, the use of appropriate design and analytical tools will provide their more accurate cardiovascular safety assessment in the real-world setting.
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Affiliation(s)
- Laurent Azoulay
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada .,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada.,Gerald Bronfman Department of Oncology, McGill University, Montreal, Canada
| | - Samy Suissa
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada.,Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada
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Chong CR, Clarke K, Levelt E. Metabolic Remodeling in Diabetic Cardiomyopathy. Cardiovasc Res 2017; 113:422-430. [PMID: 28177068 PMCID: PMC5412022 DOI: 10.1093/cvr/cvx018] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/02/2017] [Indexed: 02/07/2023] Open
Abstract
Diabetes is a risk factor for heart failure and cardiovascular mortality with specific changes to myocardial metabolism, energetics, structure, and function. The gradual impairment of insulin production and signalling in diabetes is associated with elevated plasma fatty acids and increased myocardial free fatty acid uptake and activation of the transcription factor PPARα. The increased free fatty acid uptake results in accumulation of toxic metabolites, such as ceramide and diacylglycerol, activation of protein kinase C, and elevation of uncoupling protein-3. Insulin signalling and glucose uptake/oxidation become further impaired, and mitochondrial function and ATP production become compromised. Increased oxidative stress also impairs mitochondrial function and disrupts metabolic pathways. The diabetic heart relies on free fatty acids (FFA) as the major substrate for oxidative phosphorylation and is unable to increase glucose oxidation during ischaemia or hypoxia, thereby increasing myocardial injury, especially in ageing female diabetic animals. Pharmacological activation of PPARγ in adipose tissue may lower plasma FFA and improve recovery from myocardial ischaemic injury in diabetes. Not only is the diabetic heart energetically-impaired, it also has early diastolic dysfunction and concentric remodelling. The contractile function of the diabetic myocardium negatively correlates with epicardial adipose tissue, which secretes proinflammatory cytokines, resulting in interstitial fibrosis. Novel pharmacological strategies targeting oxidative stress seem promising in preventing progression of diabetic cardiomyopathy, although clinical evidence is lacking. Metabolic agents that lower plasma FFA or glucose, including PPARγ agonism and SGLT2 inhibition, may therefore be promising options.
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Affiliation(s)
- Cher-Rin Chong
- 1 Department of Physiology, Anatomy and Genetics, University of Oxford
| | - Kieran Clarke
- 1 Department of Physiology, Anatomy and Genetics, University of Oxford
| | - Eylem Levelt
- 2 Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital
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Editorial commentary: Anti-glycemic drugs and heart failure—A new era. Trends Cardiovasc Med 2017; 27:152-154. [DOI: 10.1016/j.tcm.2016.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 08/10/2016] [Indexed: 11/18/2022]
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Pathogenesis, Clinical Features and Treatment of Diabetic Cardiomyopathy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1067:197-217. [DOI: 10.1007/5584_2017_105] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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40
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Fitchett DH, Udell JA, Inzucchi SE. Heart failure outcomes in clinical trials of glucose‐lowering agents in patients with diabetes. Eur J Heart Fail 2016; 19:43-53. [DOI: 10.1002/ejhf.633] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 07/08/2016] [Accepted: 07/09/2016] [Indexed: 01/27/2023] Open
Affiliation(s)
| | - Jacob A. Udell
- Toronto General Hospital and Women's College Hospital University of Toronto Canada
| | - Silvio E. Inzucchi
- Section of Endocrinology Yale University School of Medicine New Haven CT USA
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Toh S, Hampp C, Reichman ME, Graham DJ, Balakrishnan S, Pucino F, Hamilton J, Lendle S, Iyer A, Rucker M, Pimentel M, Nathwani N, Griffin MR, Brown NJ, Fireman BH. Risk for Hospitalized Heart Failure Among New Users of Saxagliptin, Sitagliptin, and Other Antihyperglycemic Drugs: A Retrospective Cohort Study. Ann Intern Med 2016; 164:705-14. [PMID: 27110660 PMCID: PMC5178978 DOI: 10.7326/m15-2568] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Recent postmarketing trials produced conflicting results about the risk for hospitalized heart failure (hHF) associated with dipeptidyl peptidase-4 (DPP-4) inhibitors, creating uncertainty about the safety of these antihyperglycemic agents. OBJECTIVE To examine the associations of hHF with saxagliptin and sitagliptin. DESIGN Population-based, retrospective, new-user cohort study. SETTING 18 health insurance and health system data partners in the U.S. Food and Drug Administration's Mini-Sentinel program. PATIENTS Patients aged 18 years or older with type 2 diabetes who initiated therapy with saxagliptin, sitagliptin, pioglitazone, second-generation sulfonylureas, or long-acting insulin products from 2006 to 2013. MEASUREMENTS Hospitalized HF, identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes 402.x1, 404.x1, 404.x3, and 428.xx recorded as the principal discharge diagnosis. RESULTS 78 553 saxagliptin users and 298 124 sitagliptin users contributed an average of 7 to 9 months of follow-up data to 1 or more pairwise comparisons. The risk for hHF was not higher with DPP-4 inhibitors than with the other study drugs. The hazard ratios from the disease risk score (DRS)-stratified analyses were 0.83 (95% CI, 0.70 to 0.99) for saxagliptin versus sitagliptin, 0.63 (CI, 0.47 to 0.85) for saxagliptin versus pioglitazone, 0.69 (CI, 0.54 to 0.87) for saxagliptin versus sulfonylureas, and 0.61 (CI, 0.50 to 0.73) for saxagliptin versus insulin. The DRS-stratified hazard ratios were 0.74 (CI, 0.64 to 0.85) for sitagliptin versus pioglitazone, 0.86 (CI, 0.77 to 0.95) for sitagliptin versus sulfonylureas, and 0.71 (CI, 0.64 to 0.78) for sitagliptin versus insulin. Results from the 1:1 propensity score-matched analyses were similar. Results were also similar in subgroups of patients with and without prior cardiovascular disease and in a subgroup defined by the 2 highest DRS deciles. LIMITATION Residual confounding and short follow-up. CONCLUSION In this large cohort study, a higher risk for hHF was not observed in users of saxagliptin or sitagliptin compared with other selected antihyperglycemic agents. PRIMARY FUNDING SOURCE U.S. Food and Drug Administration.
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Fu AZ, Johnston SS, Ghannam A, Tsai K, Cappell K, Fowler R, Riehle E, Cole AL, Kalsekar I, Sheehan J. Association Between Hospitalization for Heart Failure and Dipeptidyl Peptidase 4 Inhibitors in Patients With Type 2 Diabetes: An Observational Study. Diabetes Care 2016; 39:726-34. [PMID: 26740636 DOI: 10.2337/dc15-0764] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 12/05/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine, among patients with type 2 diabetes, the association between hospitalization for heart failure (hHF) and treatment with dipeptidyl peptidase 4 inhibitors (DPP-4is) versus sulfonylureas (SUs), and treatment with saxagliptin versus sitagliptin. RESEARCH DESIGN AND METHODS This was a retrospective, observational study using a U.S. insurance claims database. Patients initiated treatment between 1 August 2010 and 30 August 2013, and had no use of the comparator treatments in the prior 12 months (baseline). Each comparison consisted of patients matched 1:1 on a propensity score. Time to each outcome was compared between matched groups using Cox models. Analyses were stratified by the presence of baseline cardiovascular disease (CVD). Secondary analyses examined associations between comparator treatments and other selected cardiovascular events. RESULTS After matching, the study included 218,556 patients in comparisons of DPP-4i and SU, and 112,888 in comparisons of saxagliptin and sitagliptin. The hazard ratios (HRs) of hHF were as follows: DPP-4i versus SU (reference): HR 0.95 (95% CI 0.78-1.15), P = 0.580 for patients with baseline CVD; HR 0.59 (95% CI 0.38-0.89), P = 0.013 for patients without baseline CVD; saxagliptin versus sitagliptin (reference): HR 0.95 (95% CI 0.70-1.28), P = 0.712 for patients with baseline CVD; HR 0.99 (95% CI 0.56-1.75), P = 0.972 for patients without baseline CVD. Comparisons of the individual secondary and composite cardiovascular outcomes followed a similar pattern. CONCLUSIONS In patients with type 2 diabetes, there was no association between hHF, or other selected cardiovascular outcomes, and treatment with a DPP-4i relative to SU or treatment with saxagliptin relative to sitagliptin.
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Affiliation(s)
- Alex Z Fu
- Georgetown University Medical Center, Washington, DC
| | | | - Ameen Ghannam
- AstraZeneca Pharmaceuticals, LP, Fort Washington, PA
| | | | | | | | | | | | | | - John Sheehan
- AstraZeneca Pharmaceuticals, LP, Fort Washington, PA
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Abdelmoneim AS, Eurich DT, Senthilselvan A, Qiu W, Simpson SH. Dose-response relationship between sulfonylureas and major adverse cardiovascular events in elderly patients with type 2 diabetes. Pharmacoepidemiol Drug Saf 2016; 25:1186-1195. [DOI: 10.1002/pds.4014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Ahmed S. Abdelmoneim
- Faculty of Pharmacy and Pharmaceutical Sciences; University of Alberta; Edmonton AB Canada
- Alliance for Canadian Health Outcomes Research in Diabetes; University of Alberta; Edmonton AB Canada
| | - Dean T. Eurich
- Alliance for Canadian Health Outcomes Research in Diabetes; University of Alberta; Edmonton AB Canada
- School of Public Health; University of Alberta; Edmonton AB Canada
| | | | - Weiyu Qiu
- Alliance for Canadian Health Outcomes Research in Diabetes; University of Alberta; Edmonton AB Canada
| | - Scot H. Simpson
- Faculty of Pharmacy and Pharmaceutical Sciences; University of Alberta; Edmonton AB Canada
- Alliance for Canadian Health Outcomes Research in Diabetes; University of Alberta; Edmonton AB Canada
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Shah BR, Lipscombe LL. Clinical diabetes research using data mining: a Canadian perspective. Can J Diabetes 2016; 39:235-8. [PMID: 26004906 DOI: 10.1016/j.jcjd.2015.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 02/11/2015] [Accepted: 02/23/2015] [Indexed: 11/18/2022]
Abstract
With the advent of the digitization of large amounts of information and the computer power capable of analyzing this volume of information, data mining is increasingly being applied to medical research. Datasets created for administration of the healthcare system provide a wealth of information from different healthcare sectors, and Canadian provinces' single-payer universal healthcare systems mean that data are more comprehensive and complete in this country than in many other jurisdictions. The increasing ability to also link clinical information, such as electronic medical records, laboratory test results and disease registries, has broadened the types of data available for analysis. Data-mining methods have been used in many different areas of diabetes clinical research, including classic epidemiology, effectiveness research, population health and health services research. Although methodologic challenges and privacy concerns remain important barriers to using these techniques, data mining remains a powerful tool for clinical research.
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Affiliation(s)
- Baiju R Shah
- Department of Medicine, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Toronto, Canada; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.
| | - Lorraine L Lipscombe
- Department of Medicine, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Toronto, Canada; Department of Medicine, Women's College Hospital, Toronto, Canada
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Chen CB, Lin M, Eurich DT, Johnson JA. Safety of Concomitant Metformin and Proton Pump Inhibitor Use: A Population Retrospective Cohort Study. Clin Ther 2016; 38:1392-1400. [PMID: 27061884 DOI: 10.1016/j.clinthera.2016.03.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/04/2016] [Accepted: 03/14/2016] [Indexed: 01/08/2023]
Abstract
PURPOSE The purpose of this study was to investigate the effect of concomitant use on important clinical outcomes. METHODS In this retrospective cohort study, a cohort of new metformin users was identified between 2004 and 2010 and followed up until termination of insurance coverage, December 31, 2010, or the outcomes were reached. The primary outcome was a composite of time to all-cause mortality or hospitalization; our secondary outcome was time to cardiovascular hospitalization. Exposures to metformin, a proton pump inhibitor (PPI), and/or a histamine2 receptor antagonist (H2RA) were compared with a Cox proportional hazards model after adjustment. FINDINGS Relative to metformin-only users, metformin and PPI users were at increased risk of the primary outcome (adjusted hazard ratio [HR] = 1.55; 95% CI, 1.46-1.64); metformin and H2RA users also had an elevated risk (adjusted HR = 1.29; 95% CI, 0.97-1.70). Similar patterns were seen with cardiovascular-specific hospitalization. Compared with no drug use, metformin users had an increased risk of the primary outcome, but risk was substantially elevated when patients were taking PPIs or H2RAs, alone or in combination with metformin. IMPLICATIONS Concomitant use of metformin and a PPI or metformin and an H2RA were associated with an increased risk of death or hospitalization. This finding suggests that the harm observed may not be due to a specific drug interaction but uncontrolled confounding secondary to an increased risk in those patients using a PPI or H2RA.
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Affiliation(s)
- Christopher B Chen
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Mu Lin
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey A Johnson
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada.
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Kappel BA, Marx N, Federici M. Oral hypoglycemic agents and the heart failure conundrum: Lessons from and for outcome trials. Nutr Metab Cardiovasc Dis 2015; 25:697-705. [PMID: 26164634 DOI: 10.1016/j.numecd.2015.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/13/2015] [Accepted: 06/13/2015] [Indexed: 11/23/2022]
Abstract
AIM Type 2 diabetes is not only an independent risk factor for cardiovascular (CV) disease but is also associated with a greater incidence of heart failure (HF). The aim of this review is to examine the effects of oral antidiabetic drugs on CV disease and HF. DATA SYNTHESIS Trials of anti-diabetic agents are now designed to assess CV safety, but frequently HF is not included as a primary endpoint. However, HF in patients with diabetes is more frequent than other CV events and seems to be underestimated. A burning question is therefore if the most used trial design to monitor CV safety, i.e. non-inferiority, allows clinical translation of trial findings. Available data further suggest that the CV effects of anti-diabetic drugs may be rather class-specific and are only partly due to their glucose-lowering actions. Metformin, recommended as first line in most guidelines, shows positive CV effects while other classes like thiazolidinediones may precipitate HF. Experimental results on the relatively novel dipeptidyl peptidase IV (DPP IV) inhibitors imply CV protective effects, but the non-inferiority trials published to date show an overall neutral CV outcome and a potential increase in HF by saxagliptin. However, results on sitagliptin of the recently released TECOS indicate that HF is not a class-dependent effect of DPP IV inhibitors. CONCLUSION Further basic research and long-term outcome studies to clarify the effects of antidiabetic agents on CV and HF are required so that we can select the optimal antidiabetic therapy for our patients.
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Affiliation(s)
- B A Kappel
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy; Department of Internal Medicine I, University Hospital Aachen, Germany
| | - N Marx
- Department of Internal Medicine I, University Hospital Aachen, Germany
| | - M Federici
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy; Center for Atherosclerosis, Policlinico Tor Vergata, Rome, Italy.
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Abstract
Individuals with diabetes are not only at high risk of developing heart failure but are also at increased risk of dying from it. Fortunately, antiheart failure therapies such as angiotensin-converting-enzyme inhibitors, β blockers and mineralocorticoid-receptor antagonists work similarly well in individuals with diabetes as in individuals without the disease. Response to intensive glycaemic control and the various classes of antihyperglycaemic agent therapy is substantially less well understood. Insulin, for example, induces sodium retention and thiazolidinediones increase the risk of heart failure. The need for new glucose-lowering drugs to show cardiovascular safety has led to the unexpected finding of an increase in the risk of admission to hospital for heart failure in patients treated with the dipeptidylpeptidase-4 (DPP4) inhibitor, saxagliptin, compared with placebo. Here we review the relation between glycaemic control and heart failure risk, focusing on the state of knowledge for the various types of antihyperglycaemic drugs that are used at present.
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Affiliation(s)
- Richard E Gilbert
- Division of Endocrinology, St Michael's Hospital, University of Toronto, On, Canada.
| | - Henry Krum
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia
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Eriksson L, Nyström T. Antidiabetic agents and endothelial dysfunction - beyond glucose control. Basic Clin Pharmacol Toxicol 2015; 117:15-25. [PMID: 25827165 DOI: 10.1111/bcpt.12402] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 03/24/2015] [Indexed: 12/15/2022]
Abstract
Diabetes is rapidly increasing worldwide, and the number of patients suffering from diabetes is projected to rise by 50% over the next 25 years, then affecting almost 600 million adults. Type 2 diabetes comprises 90-95% of all people with diabetes, and they constitute a patient group that carries a high burden of cardiovascular disease. The relationship between hyperglycaemia and macrovascular complications is still uncertain, at least in terms of the possibility of reducing cardiovascular events solely by improving glycaemic control. This MiniReview has thus focused on the effect of common antidiabetic agents, with emphasis on glucagon-like peptide-1, on the endothelial cells of the vasculature. Patients with type 2 diabetes suffer a two to four times higher risk of myocardial infarction and stroke than healthy persons. In addition to this, patients with diabetes have an increased atherosclerotic burden. Endothelial dysfunction is thought to be an early and important predictor of atherosclerosis and cardiovascular disease, and in people with type 2 diabetes, endothelial dysfunction is a common finding. It is therefore of importance to consider whether drugs used within the clinical management of Type 2 diabetes mellitus (T2DM) exert direct and positive effects on the vasculature independent of their glucose-lowering ability. This might serve to limit the adverse consequences of the macrovascular complications of T2DM, as dysfunction of endothelial cells is believed to contribute to a premature development of atherosclerosis.
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Affiliation(s)
- Linnéa Eriksson
- Division of Vascular Surgery, Department of Molecular Medicine and Surgery, Centre for Molecular Medicine, Karolinska Institutet, Solna, Sweden
| | - Thomas Nyström
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm South Hospital, Stockholm, Sweden
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49
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Wang Y, Negishi T, Negishi K, Marwick TH. Prediction of heart failure in patients with type 2 diabetes mellitus- a systematic review and meta-analysis. Diabetes Res Clin Pract 2015; 108:55-66. [PMID: 25686509 DOI: 10.1016/j.diabres.2015.01.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 11/25/2014] [Accepted: 01/14/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Heart failure (HF) is a major cause of mortality and disability in type 2 diabetes mellitus (T2DM). This study sought to improve the assessment of HF risk in patients with T2DM-a step that would be critical for effective HF screening. METHODS A systematic literature search was performed on electronic databases including MEDLINE and EMBASE, using MeSH terms 'heart failure', 'risk factor', 'T2DM', 'cardiac dysfunction', 'stage B heart failure', 'incident heart failure', 'risk assessment', 'risk impact', 'risk score', 'predictor', 'prediction' and related free text terms. The search was limited to human studies in full-length publications in English language journal from 1946 to 2014. Univariable and multivariable relative risk (RR) and hazard ratio (HR) were obtained from each study. RESULTS Twenty-one studies (n=1111,569, including 507,637 subjects with T2DM) were included in this analysis with a follow-up ranging from 1 to 12 years. Associations between incident HF and risk variables described in ≥3 studies were reported. This association was greatest for insulin use (HR 2.48; 1.24-4.99), HbA1c 7.0-8.0% (2.41; 1.62-3.59), 5 years increase in age (1.47; 1.25-1.73), fasting glucose (1.28; 1.10-1.51 per standard deviation) and HbA1c (1.18; 1.14-1.23 each 1% increase). After adjustment for confounders, there were strong associations with coronary artery disease (1.77; 1.31, 2.39), HbA1c ≥ 10% (1.66; 1.45-1.89), insulin use (1.43; 1.14-1.79), HbA1c 9.0-10.0% (1.31; 1.14-1.50), fasting glucose (1.27; 1.10-1.47 per standard deviation) and 5 years increase in age (1.26; 1.13-1.40). CONCLUSION Among patients with T2DM, five common clinical variables are associated with significantly increased risk of incident HF.
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Affiliation(s)
- Ying Wang
- Menzies Research Institute Tasmania, 17 Liverpool Street, Hobart, TAS, Australia
| | - Tomoko Negishi
- Menzies Research Institute Tasmania, 17 Liverpool Street, Hobart, TAS, Australia
| | - Kazuaki Negishi
- Menzies Research Institute Tasmania, 17 Liverpool Street, Hobart, TAS, Australia
| | - Thomas H Marwick
- Menzies Research Institute Tasmania, 17 Liverpool Street, Hobart, TAS, Australia.
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50
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Parry HM, Deshmukh H, Levin D, Van Zuydam N, Elder DHJ, Morris AD, Struthers AD, Palmer CNA, Doney ASF, Lang CC. Both high and low HbA1c predict incident heart failure in type 2 diabetes mellitus. Circ Heart Fail 2015; 8:236-42. [PMID: 25561089 PMCID: PMC4366571 DOI: 10.1161/circheartfailure.113.000920] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Type 2 diabetes mellitus is an independent risk factor for heart failure development, but the relationship between incident heart failure and antecedent glycemia has not been evaluated. METHODS AND RESULTS The Genetics of Diabetes Audit and Research in Tayside Study study holds data for 8683 individuals with type 2 diabetes mellitus. Dispensed prescribing, hospital admission data, and echocardiography reports were linked to extract incident heart failure cases from December 1998 to August 2011. All available HbA1c measures until heart failure development or end of study were used to model HbA1c time-dependently. Individuals were observed from study enrolment until heart failure development or end of study. Proportional hazard regression calculated heart failure development risk associated with specific HbA1c ranges accounting for comorbidities associated with heart failure, including blood pressure, body mass index, and coronary artery disease. Seven hundred and one individuals with type 2 diabetes mellitus (8%) developed heart failure during follow up (mean 5.5 years, ±2.8 years). Time-updated analysis with longitudinal HbA1c showed that both HbA1c <6% (hazard ratio =1.60; 95% confidence interval, 1.38-1.86; P value <0.0001) and HbA1c >10% (hazard ratio =1.80; 95% confidence interval, 1.60-2.16; P value <0.0001) were independently associated with the risk of heart failure. CONCLUSIONS Both high and low HbA1c predicted heart failure development in our cohort, forming a U-shaped relationship.
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Affiliation(s)
- Helen M Parry
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom.
| | - Harshal Deshmukh
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Daniel Levin
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Natalie Van Zuydam
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Douglas H J Elder
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Andrew D Morris
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Allan D Struthers
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Colin N A Palmer
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Alex S F Doney
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
| | - Chim C Lang
- From the Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital, University of Dundee, Dundee, United Kingdom
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