1
|
Li X, Zhou X, Gao L. Diabetes and Heart Failure: A Literature Review, Reflection and Outlook. Biomedicines 2024; 12:1572. [PMID: 39062145 PMCID: PMC11274420 DOI: 10.3390/biomedicines12071572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/08/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
Heart failure (HF) is a complex clinical syndrome caused by structural or functional dysfunction of the ventricular filling or blood supply. Diabetes mellitus (DM) is an independent predictor of mortality for HF. The increase in prevalence, co-morbidity and hospitalization rates of both DM and HF has further fueled the possibility of overlapping disease pathology between the two. For decades, antidiabetic drugs that are known to definitively increase the risk of HF are the thiazolidinediones (TZDs) and saxagliptin in the dipeptidyl peptidase-4 (DPP-4) inhibitor, and insulin, which causes sodium and water retention, and whether metformin is effective or safe for HF is not clear. Notably, sodium-glucose transporter 2 (SGLT2) inhibitors and partial glucagon-like peptide-1 receptor agonists (GLP-1 RA) all achieved positive results for HF endpoints, with SGLT2 inhibitors in particular significantly reducing the composite endpoint of cardiovascular mortality and hospitalization for heart failure (HHF). Further understanding of the mutual pathophysiological mechanisms between HF and DM may facilitate the detection of novel therapeutic targets to improve the clinical outcome. This review focuses on the association between HF and DM, emphasizing the efficacy and safety of antidiabetic drugs and HF treatment. In addition, recent therapeutic advances in HF and the important mechanisms by which SGLT2 inhibitors/mineralocorticoid receptor antagonist (MRA)/vericiguat contribute to the benefits of HF are summarized.
Collapse
Affiliation(s)
| | | | - Ling Gao
- Department of Endocrinology, Renmin Hospital, Wuhan University, Wuhan 430060, China; (X.L.); (X.Z.)
| |
Collapse
|
2
|
Li J, Xie Y, Zheng S, He H, Wang Z, Li X, Jiao S, Liu D, Yang F, Zhao H, Li P, Sun Y. Targeting autophagy in diabetic cardiomyopathy: From molecular mechanisms to pharmacotherapy. Biomed Pharmacother 2024; 175:116790. [PMID: 38776677 DOI: 10.1016/j.biopha.2024.116790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 05/13/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
Diabetic cardiomyopathy (DCM) is a cardiac microvascular complication caused by metabolic disorders. It is characterized by myocardial remodeling and dysfunction. The pathogenesis of DCM is associated with abnormal cellular metabolism and organelle accumulation. Autophagy is thought to play a key role in the diabetic heart, and a growing body of research suggests that modulating autophagy may be a potential therapeutic strategy for DCM. Here, we have summarized the major signaling pathways involved in the regulation of autophagy in DCM, including Adenosine 5'-monophosphate-activated protein kinase (AMPK), mechanistic target of rapamycin (mTOR), Forkhead box subfamily O proteins (FOXOs), Sirtuins (SIRTs), and PTEN-inducible kinase 1 (PINK1)/Parkin. Given the significant role of autophagy in DCM, we further identified natural products and chemical drugs as regulators of autophagy in the treatment of DCM. This review may help to better understand the autophagy mechanism of drugs for DCM and promote their clinical application.
Collapse
Affiliation(s)
- Jie Li
- China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Beijing, China
| | - Yingying Xie
- Department of Cardiology, China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shuwen Zheng
- Beijing University of Chinese Medicine School of Traditional Chinese Medicine, Beijing, China
| | - Haoming He
- Department of Cardiology, China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhe Wang
- Department of Cardiology, China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xuexi Li
- Department of Cardiology, China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Siqi Jiao
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Dong Liu
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Furong Yang
- Beijing University of Chinese Medicine School of Traditional Chinese Medicine, Beijing, China
| | - Hailing Zhao
- Beijing Key Laboratory for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China.
| | - Ping Li
- Beijing Key Laboratory for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China.
| | - Yihong Sun
- Department of Cardiology, China-Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China; Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.
| |
Collapse
|
3
|
Li J, Liu Y, Hao P. Re-evaluation of dipeptidyl peptidase-4 inhibitors in patients with heart failure and diabetes mellitus. Diabetes Res Clin Pract 2023:110798. [PMID: 37356725 DOI: 10.1016/j.diabres.2023.110798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVES The question of whether dipeptidyl peptidase-4 inhibitors (DPP-4i) should be preferred as new glucose-lowering agents in heart failure is controversial. This studyaimed to evaluate the effects of DPP-4i treatment on all-cause mortality and cardiovascular outcomes in patients with heart failure. METHODS We searched for available studies of DPP-4i therapy in heart failure and performed a pooled analysis. Outcomes included all-cause mortality, cardiovascular death, hospitalization for heart failure, left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), acute coronary syndrome, and acute myocardial infarction. RESULTS Treatment with DPP-4i did not reduce the risk of all-cause death, cardiovascular death, or hospitalization for heart failure. Subgroup analyses showed that DPP-4i significantly reduced all-cause mortality in trials with >40% female patients (OR 0.30, 95% CI [0.16, 0.58], P=0.0003) and in trials with >20% patients with heart failure with preserved ejection fraction (HFpEF) (OR 0.34, 95% CI [0.19, 0.60], P=0.0003). Changes in LVEF and LVEDV showed no statistical differences between the 2 groups. Accordingly, DPP-4i did not alter the risk of acute coronary syndrome and acute myocardial infarction. CONCLUSIONS DPP-4i may reduce all-cause mortality in heart failure patients in subgroups of women and HFpEF and has a high coronary safety profile.
Collapse
Affiliation(s)
- Jiaoran Li
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of Cardiology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, PR China
| | - Yanping Liu
- Department of Radiology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, PR China
| | - Panpan Hao
- National Key Laboratory for Innovation and Transformation of Luobing Theory, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Department of Cardiology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong, PR China.
| |
Collapse
|
4
|
Saini K, Sharma S, Khan Y. DPP-4 inhibitors for treating T2DM - hype or hope? an analysis based on the current literature. Front Mol Biosci 2023; 10:1130625. [PMID: 37287751 PMCID: PMC10242023 DOI: 10.3389/fmolb.2023.1130625] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 05/08/2023] [Indexed: 06/09/2023] Open
Abstract
DPP-4 inhibition is an interesting line of therapy for treating Type 2 Diabetes Mellitus (T2DM) and is based on promoting the incretin effect. Here, the authors have presented a brief appraisal of DPP-4 inhibitors, their modes of action, and the clinical efficiency of currently available drugs based on DPP-4 inhibitors. The safety profiles as well as future directions including their potential application in improving COVID-19 patient outcomes have also been discussed in detail. This review also highlights the existing queries and evidence gaps in DPP-4 inhibitor research. Authors have concluded that the excitement surrounding DPP-4 inhibitors is justified because in addition to controlling blood glucose level, they are good at managing risk factors associated with diabetes.
Collapse
|
5
|
Metformin treatment is associated with improved outcome in patients with diabetes and advanced heart failure (HFrEF). Sci Rep 2022; 12:13038. [PMID: 35906276 PMCID: PMC9338272 DOI: 10.1038/s41598-022-17327-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022] Open
Abstract
The role of metformin (MET) in the treatment of patients with advanced HFrEF and type 2 diabetes mellitus (DM) is not firmly established. We studied the impact of MET on metabolic profile, quality of life (QoL) and survival in these patients. A total of 847 stable patients with advanced HFrEF (57.4 ± 11.3 years, 67.7% NYHA III/IV, LVEF 23.6 ± 5.8%) underwent clinical and laboratory evaluation and were prospectively followed for a median of 1126 (IQRs 410; 1781) days for occurrence of death, urgent heart transplantation or mechanical circulatory support implantation. A subgroup of 380 patients (44.9%) had DM, 87 of DM patients (22.9%) were treated with MET. Despite worse insulin sensitivity and more severe DM (higher BMI, HbA1c, worse insulin resistance), MET-treated patients exhibited more stable HF marked by lower BNP level (400 vs. 642 ng/l), better LV and RV function, lower mitral and tricuspid regurgitation severity, were using smaller doses of diuretics (all p < 0.05). Further, they had higher eGFR (69.23 vs. 63.34 ml/min/1.73 m2) and better QoL (MLHFQ: 36 vs. 48 points, p = 0.002). Compared to diabetics treated with other glucose-lowering agents, MET-treated patients had better event-free survival even after adjustment for BNP, BMI and eGFR (p = 0.035). Propensity score-matched analysis with 17 covariates yielded 81 pairs of patients and showed a significantly better survival for MET-treated subgroup (p = 0.01). MET treatment in patients with advanced HFrEF and DM is associated with improved outcome by mechanisms beyond the improvement of blood glucose control.
Collapse
|
6
|
Phang RJ, Ritchie RH, Hausenloy DJ, Lees JG, Lim SY. Cellular interplay between cardiomyocytes and non-myocytes in diabetic cardiomyopathy. Cardiovasc Res 2022; 119:668-690. [PMID: 35388880 PMCID: PMC10153440 DOI: 10.1093/cvr/cvac049] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/16/2022] [Accepted: 03/05/2022] [Indexed: 11/13/2022] Open
Abstract
Patients with Type 2 diabetes mellitus (T2DM) frequently exhibit a distinctive cardiac phenotype known as diabetic cardiomyopathy. Cardiac complications associated with T2DM include cardiac inflammation, hypertrophy, fibrosis and diastolic dysfunction in the early stages of the disease, which can progress to systolic dysfunction and heart failure. Effective therapeutic options for diabetic cardiomyopathy are limited and often have conflicting results. The lack of effective treatments for diabetic cardiomyopathy is due in part, to our poor understanding of the disease development and progression, as well as a lack of robust and valid preclinical human models that can accurately recapitulate the pathophysiology of the human heart. In addition to cardiomyocytes, the heart contains a heterogeneous population of non-myocytes including fibroblasts, vascular cells, autonomic neurons and immune cells. These cardiac non-myocytes play important roles in cardiac homeostasis and disease, yet the effect of hyperglycaemia and hyperlipidaemia on these cell types are often overlooked in preclinical models of diabetic cardiomyopathy. The advent of human induced pluripotent stem cells provides a new paradigm in which to model diabetic cardiomyopathy as they can be differentiated into all cell types in the human heart. This review will discuss the roles of cardiac non-myocytes and their dynamic intercellular interactions in the pathogenesis of diabetic cardiomyopathy. We will also discuss the use of sodium-glucose cotransporter 2 inhibitors as a therapy for diabetic cardiomyopathy and their known impacts on non-myocytes. These developments will no doubt facilitate the discovery of novel treatment targets for preventing the onset and progression of diabetic cardiomyopathy.
Collapse
Affiliation(s)
- Ren Jie Phang
- O'Brien Institute Department, St Vincent's Institute of Medical Research, Fitzroy, Victoria 3065, Australia.,Departments of Surgery and Medicine, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Rebecca H Ritchie
- School of Biosciences, Parkville, Victoria 3010, Australia.,Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria 3052, Australia.,Department of Pharmacology, Monash University, Clayton, Victoria 3800, Australia
| | - Derek J Hausenloy
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore.,Cardiovascular and Metabolic Disorders Programme, Duke-NUS Medical School, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,The Hatter Cardiovascular Institute, University College London, London, UK.,Cardiovascular Research Center, College of Medical and Health Sciences, Asia University, Taichung City, Taiwan
| | - Jarmon G Lees
- O'Brien Institute Department, St Vincent's Institute of Medical Research, Fitzroy, Victoria 3065, Australia.,Departments of Surgery and Medicine, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Shiang Y Lim
- O'Brien Institute Department, St Vincent's Institute of Medical Research, Fitzroy, Victoria 3065, Australia.,Departments of Surgery and Medicine, University of Melbourne, Parkville, Victoria 3010, Australia.,National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore
| |
Collapse
|
7
|
Ye H, He Y, Zheng C, Wang F, Yang M, Lin J, Xu R, Zhang D. Type 2 Diabetes Complicated With Heart Failure: Research on Therapeutic Mechanism and Potential Drug Development Based on Insulin Signaling Pathway. Front Pharmacol 2022; 13:816588. [PMID: 35308248 PMCID: PMC8927800 DOI: 10.3389/fphar.2022.816588] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/31/2022] [Indexed: 01/16/2023] Open
Abstract
Type 2 diabetes mellitus (T2DM) and heart failure (HF) are diseases characterized by high morbidity and mortality. They often occur simultaneously and increase the risk of each other. T2DM complicated with HF, as one of the most dangerous disease combinations in modern medicine, is more common in middle-aged and elderly people, making the treatment more difficult. At present, the combination of blood glucose control and anti-heart failure is a common therapy for patients with T2DM complicated with HF, but their effect is not ideal, and many hypoglycemic drugs have the risk of heart failure. Abnormal insulin signaling pathway, as a common pathogenic mechanism in T2DM and HF, could lead to pathological features such as insulin resistance (IR), myocardial energy metabolism disorders, and vascular endothelial disorders. The therapy based on the insulin signaling pathway may become a specific therapeutic target for T2DM patients with HF. Here, we reviewed the mechanisms and potential drugs of insulin signaling pathway in the treatment of T2DM complicated with HF, with a view to opening up a new perspective for the treatment of T2DM patients with HF and the research and development of new drugs.
Collapse
Affiliation(s)
- Hui Ye
- State Key Laboratory of Southwestern Chinese Medicine Resources, Pharmacy School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yanan He
- State Key Laboratory of Southwestern Chinese Medicine Resources, Pharmacy School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Chuan Zheng
- TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Fang Wang
- State Key Laboratory of Innovation Medicine and High Efficiency and Energy Saving Pharmaceutical Equipment, Jiangxi University of Traditional Chinese Medicine, Nanchang, China
| | - Ming Yang
- State Key Laboratory of Innovation Medicine and High Efficiency and Energy Saving Pharmaceutical Equipment, Jiangxi University of Traditional Chinese Medicine, Nanchang, China
| | - Junzhi Lin
- TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Runchun Xu
- State Key Laboratory of Southwestern Chinese Medicine Resources, Pharmacy School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Dingkun Zhang
- State Key Laboratory of Southwestern Chinese Medicine Resources, Pharmacy School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| |
Collapse
|
8
|
Charoo NA, Abdallah DB, Bakheit AA, Haque KU, Hassan HA, Abrahamsson B, Cristofoletti R, Langguth P, Mehta M, Parr A, Polli JE, Shah VP, Tajiri T, Dressman J. Biowaiver Monograph for Immediate-Release Solid Oral Dosage Forms: Sitagliptin Phosphate Monohydrate. J Pharm Sci 2021; 111:2-13. [PMID: 34597625 DOI: 10.1016/j.xphs.2021.09.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 01/21/2023]
Abstract
Sitagliptin is an antihyperglycemic drug used in adults for the treatment of diabetes Type 2. Literature data and in-house experiments were applied in this monograph to assess whether methods based on the Biopharmaceutics Classification System (BCS) could be used to assess the bioequivalence of solid immediate-release (IR) oral dosage forms containing sitagliptin phosphate monohydrate, as an alternative to a pharmacokinetic study in human volunteers. The solubility and permeability characteristics of sitagliptin were reviewed according to the BCS, along with dissolution, therapeutic index, therapeutic applications, pharmacokinetics, pharmacodynamic characteristics, reports of bioequivalence (BE) / bioavailability problems, data on interactions between the drug and excipients and other data germane to the subject. All data reviewed in this monograph unambiguously support classification of sitagliptin as a BCS Class 1 drug. In light of its broad therapeutic index and lack of severe adverse effects, the clinical risks associated with moderately supraoptimal doses were deemed inconsequential, as were the risks associated with moderately suboptimal doses. Taking all evidence into consideration, it was concluded that the BCS-based biowaiver can be implemented for solid IR oral drug products containing sitagliptin phosphate monohydrate, provided (a) the test product is formulated solely with excipients commonly present in solid IR oral drug products approved in ICH or associated countries and used in amounts commonly applied in this type of product, (b) data in support of the BCS-based biowaiver are obtained using the methods recommended by the WHO, FDA, EMA or ICH and (c) the test product and the comparator product (which is the innovator product in this case) meet all in vitro dissolution specifications provided in the WHO, FDA, EMA or ICH guidance.
Collapse
Affiliation(s)
- Naseem A Charoo
- Succor Pharma Solutions, Dubai Science Park, Dubai, United Arab Emirates
| | - Daud B Abdallah
- Department of Pharmaceutics, Faculty of Pharmacy, The National Ribat University, Khartoum, Sudan
| | - Ahmed Abdalla Bakheit
- Department of Pharmaceutics, Faculty of Pharmacy, The National Ribat University, Khartoum, Sudan
| | - Kashif Ul Haque
- Succor Pharma Solutions, Dubai Science Park, Dubai, United Arab Emirates
| | - Hassan Ali Hassan
- Department of Pharmaceutics, Faculty of Pharmacy, University of Khartoum, Sudan
| | - Bertil Abrahamsson
- Oral Product Development, Pharmaceutical Technology & Development, Operations AstraZeneca, Gothenburg, Sweden
| | - Rodrigo Cristofoletti
- Brazilian Health Surveillance Agency (ANVISA), Division of Bioequivalence, Brasilia, Brazil
| | - Peter Langguth
- Department of Pharmaceutical Technology and Biopharmaceutics, Johannes Gutenberg University, Mainz, Germany
| | - Mehul Mehta
- United States Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, MD, USA
| | - Alan Parr
- Bioceutics LCC, Raleigh-Durham, North Carolina, USA
| | - James E Polli
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Vinod P Shah
- International Pharmaceutical Federation (FIP), The Hague, the Netherlands
| | - Tomokazu Tajiri
- Astellas Pharma Inc, Analytical Research Laboratories, Yaizu, Japan
| | - Jennifer Dressman
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt am Main, Germany.
| |
Collapse
|
9
|
Cardiovascular Safety and Benefits of Noninsulin Antihyperglycemic Drugs for the Treatment of Type 2 Diabetes Mellitus: Part 2. Cardiol Rev 2021; 28:219-235. [PMID: 32271194 DOI: 10.1097/crd.0000000000000311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ideal drugs to improve outcomes in type 2 diabetes mellitus (T2DM) are those with antiglycemic efficacy, as well as cardiovascular safety that has to be determined in appropriately designed cardiovascular outcome trials as mandated by regulatory agencies. The more recent antihyperglycemic medications have shown promise with regards to cardiovascular disease (CVD) risk reduction in T2DM patients at a high cardiovascular risk. Sodium glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists are associated with better cardiovascular outcomes and mortality in T2DM patients than are dipeptidylpeptidase-4 inhibitors, leading to the Food and Drug Administration's approval of empagliflozin to reduce mortality, and of liraglutide to reduce CVD risk in high-risk T2DM patients. For heart failure outcomes, sodium glucose cotransporter-2 inhibitors are beneficial, while glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors are neutral. Ongoing and planned randomized controlled trials of these newer drugs should clarify the possibility of class effects and of CVD risk reduction benefits in low-moderate cardiovascular risk patients. While we eagerly await the results on ongoing studies, these medications should be appropriately prescribed in T2DM patients with baseline CVD or those at a high CVD risk after carefully evaluating the elevated risk for adverse events like gastrointestinal disturbances, bladder cancer, genital infections, and amputations. Studies to understand the pleotropic and novel pathophysiological mechanisms demonstrated by the sodium glucose cotransporter-2 inhibitors will shed light on the effects of the modulation of microvascular, inflammatory, and thrombotic milieu for improving the CVD risk in T2DM patients. This is part 2 of the series on noninsulin antihyperglycemic drugs for the treatment of T2DM.
Collapse
|
10
|
Muanda FT, Weir MA, Bathini L, Clemens KK, Perkovic V, Sood MM, McArthur E, Sontrop JM, Kim RB, Garg AX. Higher-Dose Sitagliptin and the Risk of Congestive Heart Failure in Older Adults with CKD. Clin J Am Soc Nephrol 2020; 15:1728-1739. [PMID: 33239410 PMCID: PMC7769019 DOI: 10.2215/cjn.08310520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/17/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Sitagliptin, a dipeptidyl peptidase-4 inhibitor, is commonly prescribed to patients with type 2 diabetes. As this drug is primarily eliminated by the kidney, a reduced dose is recommended for patients with CKD. Some evidence suggests that sitagliptin is associated with a higher risk of congestive heart failure, particularly at higher doses. We compare the 1-year risk of death or hospitalization with congestive heart failure in patients with CKD newly prescribed sitagliptin at >50 versus ≤50 mg/d. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This population-based cohort study included older adults (>66 years) with type 2 diabetes and an eGFR<45 ml/min per 1.73 m2 (but not receiving dialysis) who were newly prescribed sitagliptin between 2010 and 2017 in Ontario, Canada. We used inverse probability of treatment weighting on the basis of propensity scores to balance baseline characteristics. The primary composite outcome was death or hospitalization with congestive heart failure. Secondary outcomes included hospitalization with pancreatitis or hypoglycemia, all-cause hospitalization, and glycemic control. Weighted hazard ratios were obtained using Cox proportional hazards regression, and 95% confidence intervals were obtained using bootstrap variance estimators. RESULTS Of 9215 patients, 6518 started sitagliptin at >50 mg/d, and 2697 started sitagliptin at ≤50 mg/d. The 1-year risk of death or hospitalization with congestive heart failure did not differ significantly between groups (79 versus 126 events per 1000 person-years; weighted hazard ratio, 0.88; 95% confidence interval, 0.67 to 1.14); hospitalization with pancreatitis (weighted hazard ratio, 0.98; 95% confidence interval, 0.32 to 3.03) and hypoglycemia (weighted hazard ratio, 1.10; 95% confidence interval, 0.64 to 1.90) also did not differ significantly between groups. Patients starting sitagliptin at >50 mg/d had lower mean glycated hemoglobin concentrations (weighted between-group difference, -0.12%; 95% confidence interval, -0.19 to -0.06) and a lower risk of all-cause hospitalization (weighted hazard ratio, 0.81; 95% confidence interval, 0.66 to 0.98). CONCLUSIONS The risk of death or congestive heart failure was not higher in older adults with CKD starting sitagliptin at >50 versus ≤50 mg/d. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_11_25_CJN08310520_final.mp3.
Collapse
Affiliation(s)
- Flory T Muanda
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada .,Department of Epidemiology and Biostatistics, Western University, London, Canada
| | - Matthew A Weir
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Canada.,Division of Nephrology, Department of Medicine, Western University, London, Canada
| | - Lavanya Bathini
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada.,Division of Nephrology, Department of Medicine, Western University, London, Canada
| | - Kristin K Clemens
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada.,Division of Endocrinology and Metabolism, Department of Medicine, Western University, London, Canada
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Manish M Sood
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada.,The Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada
| | - Eric McArthur
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada
| | - Jessica M Sontrop
- Division of Nephrology, Department of Medicine, Western University, London, Canada
| | - Richard B Kim
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario, Canada
| | - Amit X Garg
- ICES, Kidney, Dialysis and Transplantation Research Program, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Canada.,Division of Nephrology, Department of Medicine, Western University, London, Canada
| |
Collapse
|
11
|
Breite LD, Steck M, Cutshall BT, Shah SP, Cave BE. Changing Fields-Diabetes Medications Invading the Cardiovascular Space. Curr Probl Cardiol 2020; 46:100736. [PMID: 33218786 DOI: 10.1016/j.cpcardiol.2020.100736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 10/23/2022]
Abstract
Cardiovascular disease (CVD) remains the leading cause of mortality in patients with type 2 diabetes, and treatment strategies that impact cardiovascular (CV) outcomes in this population is an area of growing interest. Pharmacologic agents that reduce CVD risk have been developed, and data supporting their use have grown extensively. Glucagon-like peptide 1 agonists and sodium-glucose cotransporter 2 inhibitors when added to metformin therapy provide the most CV benefit and should be considered in most patients. Data available suggest that sulfonylureas should be avoided in patients at risk for CVD and if a thiazolidinedione is utilized, pioglitazone may be preferred. When selecting an agent, the potential benefit, risk, and cost of each agent should be considered prior to initiation. The purpose of this review is to summarize the literature surrounding the CV effects of antidiabetic agents and to provide practical guidance on their use in patients with type 2 diabetes and CVD.
Collapse
|
12
|
El Hadidi S, Rosano G, Tamargo J, Agewall S, Drexel H, Kaski JC, Niessner A, Lewis BS, Coats AJS. Potentially Inappropriate Prescriptions in Heart Failure with Reduced Ejection Fraction (PIP-HFrEF). EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:187-210. [PMID: 32941594 DOI: 10.1093/ehjcvp/pvaa108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/12/2020] [Accepted: 09/04/2020] [Indexed: 12/13/2022]
Abstract
Heart failure (HF) is a chronic debilitating and potentially life-threatening condition. Heart Failure patients are usually at high risk of polypharmacy and consequently, potentially inappropriate prescribing leading to poor clinical outcomes. Based on the published literature, a comprehensive HF-specific prescribing review tool is compiled to avoid medications that may cause HF or harm HF patients and to optimize the prescribing practice of HF guideline-directed medical therapies. Recommendations are made in line with the last versions of ESC guidelines, ESC position papers, scientific evidence, and experts' opinions.
Collapse
Affiliation(s)
- Seif El Hadidi
- Faculty of Pharmaceutical Sciences and Pharmaceutical Industries, Future University in Egypt, New Cairo, Egypt
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy.,Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, Madrid, Spain
| | - Stefan Agewall
- Department of Cardiology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Heinz Drexel
- VIVIT Institute, Landeskrankenhaus Feldkirch, Austria
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London
| | - Alexander Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-IIT, Haifa, Israel
| | - Andrew J S Coats
- Centre of Clinical and Experimental Medicine, IRCCS San Raffaele Pisana, Rome, Italy
| |
Collapse
|
13
|
Abstract
Previous studies have demonstrated that individuals with type 2 diabetes mellitus (T2DM) have a two- to fourfold propensity to develop cardiovascular disease (CVD) than nondiabetic population, making CVD a major cause of death and disability among people with T2DM. The present treatment options for management of diabetes propose the earlier and more frequent use of new antidiabetic drugs that could control hyperglycaemia and reduce the risk of cardiovascular events. Findings from basic and clinical studies pointed out DPP-4 inhibitors as potentially novel pharmacological tools for cardioprotection. There is a growing body of evidence suggesting that these drugs have ability to protect the heart against acute ischaemia-reperfusion injury as well as reduce the size of infarction. Consequently, the prevention of degradation of the incretin hormones by the use of DPP-4 inhibitors represents a new strategy in the treatment of patients with T2DM and reduction of CV events in these patients. Here, we discuss the cardioprotective effects of DPP-4 inhibitors as well as proposed pathways that these hypoglycaemic agents target in the cardiovascular system.
Collapse
|
14
|
Abstract
Diabetes mellitus predisposes affected individuals to a significant spectrum of cardiovascular complications, one of the most debilitating in terms of prognosis is heart failure. Indeed, the increasing global prevalence of diabetes mellitus and an aging population has given rise to an epidemic of diabetes mellitus-induced heart failure. Despite the significant research attention this phenomenon, termed diabetic cardiomyopathy, has received over several decades, understanding of the full spectrum of potential contributing mechanisms, and their relative contribution to this heart failure phenotype in the specific context of diabetes mellitus, has not yet been fully resolved. Key recent preclinical discoveries that comprise the current state-of-the-art understanding of the basic mechanisms of the complex phenotype, that is, the diabetic heart, form the basis of this review. Abnormalities in each of cardiac metabolism, physiological and pathophysiological signaling, and the mitochondrial compartment, in addition to oxidative stress, inflammation, myocardial cell death pathways, and neurohumoral mechanisms, are addressed. Further, the interactions between each of these contributing mechanisms and how they align to the functional, morphological, and structural impairments that characterize the diabetic heart are considered in light of the clinical context: from the disease burden, its current management in the clinic, and where the knowledge gaps remain. The need for continued interrogation of these mechanisms (both known and those yet to be identified) is essential to not only decipher the how and why of diabetes mellitus-induced heart failure but also to facilitate improved inroads into the clinical management of this pervasive clinical challenge.
Collapse
Affiliation(s)
- Rebecca H. Ritchie
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University (Parkville campus), Parkville, Victoria 3052, Australia
| | - E. Dale Abel
- Division of Endocrinology and Metabolism, University of Iowa Carver College of Medicine, Iowa City, IA 52242, United States
- Fraternal Order of Eagles Diabetes Research Center, University of Iowa Carver College of Medicine, Iowa City, IA 52242, United States
| |
Collapse
|
15
|
Shiraki A, Oyama JI, Nishikido T, Node K. GLP-1 analog liraglutide-induced cardiac dysfunction due to energetic starvation in heart failure with non-diabetic dilated cardiomyopathy. Cardiovasc Diabetol 2019; 18:164. [PMID: 31779634 PMCID: PMC6881987 DOI: 10.1186/s12933-019-0966-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/10/2019] [Indexed: 02/06/2023] Open
Abstract
Background Glucagon-like peptide-1 (GLP-1) reduces cardiovascular events in diabetic patients; however, its counter-protective effects have also been suggested in patients with heart failure and the clear explanation for its mechanisms have not yet been offered. Methods The effects of GLP-1 analog on cardiac function and energy metabolism, especially glycemic and lipid metabolisms were elucidated using non-diabetic J2N-k hamsters which showed spontaneous dilated cardiomyopathy. J2N-k hamsters were treated with PBS (HF group), low-dose (HF-L group) or high-dose liraglutide (HF-H group). Results In failing heart, GLP-1 analog exerted further deteriorated cardiac function (e.g. positive and negative dP/dt; p = 0.01 and p = 0.002, respectively) with overt fibrosis and cardiac enlargement (heart/body weight, 5.7 ± 0.2 in HF group versus 7.6 ± 0.2 in HF-H group; p = 0.02). The protein expression of cardiac muscles indicated the energy starvation status. Indirect calorimetry showed that failing hearts consumed higher energy and carbohydrate than normal hearts; moreover, this tendency was augmented by GLP-1 analog administration. Upon 10% glucose solution loading with GLP-1 analog administration (HF-H-G group) as complementary experiments, the cardiac function and fibrosis significantly ameliorated, whereas carbohydrate utilization augmented further and lipid utilization reduced more. The prognosis of HF-H-G group also significantly improved (p = 0.025). Conclusions Glucagon-like peptide-1 analog caused the relative but desperate shortage of glycemic energy source for the failing cardiac muscles and it may restrict ATP synthesis, resulting in cardiac function deterioration. Therefore, appropriate energy supply and amount of carbohydrate intake should be carefully considered when administrating incretin-related drugs to patients with heart failure.
Collapse
Affiliation(s)
- Aya Shiraki
- Department of Cardiovascular Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Jun-Ichi Oyama
- Department of Cardiovascular Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
| | - Toshiyuki Nishikido
- Department of Cardiovascular Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| |
Collapse
|
16
|
Wilson JR, Kerman SJ, Hubers SA, Yu C, Nian H, Grouzmann E, Eugster PJ, Mayfield DS, Brown NJ. Dipeptidyl Peptidase 4 Inhibition Increases Postprandial Norepinephrine via Substance P (NK1 Receptor) During RAAS Inhibition. J Endocr Soc 2019; 3:1784-1798. [PMID: 31528826 PMCID: PMC6734191 DOI: 10.1210/js.2019-00185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 06/25/2019] [Indexed: 12/27/2022] Open
Abstract
CONTEXT Dipeptidyl peptidase 4 (DPP4) inhibitors may increase the risk of heart failure. Decreased degradation of vasoactive peptides like substance P [also degraded by angiotensin-converting enzyme (ACE)] and Y1 agonists peptide YY (PYY 1-36) and neuropeptide Y (NPY 1-36) could contribute. OBJECTIVE This study tested the hypothesis that there is an interactive effect of DPP4 inhibition and ACE inhibition (vs antihypertensive control subjects) on vasoactive peptides after a mixed meal. PARTICIPANTS AND DESIGN Fifty-three patients with type 2 diabetes and hypertension were randomized to double-blind treatment with ramipril, valsartan, or amlodipine for 15 weeks in parallel groups. During the 5th, 10th, and 15th weeks, participants also received placebo + placebo, sitagliptin 100 mg/d + placebo, and sitagliptin + aprepitant 80 mg/d in random order. On the last day of each crossover treatment, participants underwent a mixed-meal study. RESULTS Sitagliptin increased postprandial glucagon-like peptide-1 and decreased glucose in all antihypertensive groups. Sitagliptin increased NPY 1-36 and decreased Y2 agonists NPY 3-36 and PYY 3-36 in all groups. During ramipril or valsartan, but not amlodipine, sitagliptin increased postprandial norepinephrine; substance P receptor blockade with aprepitant prevented this effect. Despite increased norepinephrine, sitagliptin decreased postprandial blood pressure during ACE inhibition. CONCLUSION DPP4 inhibition increases postprandial concentrations of the Y1 agonist NPY 1-36. During treatment with an ACE inhibitor or angiotensin receptor blocker, DPP4 inhibition increased postprandial norepinephrine through a substance P receptor-dependent mechanism. Increased NPY 1-36 and norepinephrine could increase risk of heart failure but did not result in higher postprandial blood pressure.
Collapse
Affiliation(s)
- Jessica R Wilson
- Division of Clinical Pharmacology, Vanderbilt Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Endocrinology, Diabetes, and Metabolism, Vanderbilt Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Endocrinology, Diabetes and Metabolism, University of Pennsylvania Department of Medicine, Philadelphia, Pennsylvania
| | - Scott Jafarian Kerman
- Division of Clinical Pharmacology, Vanderbilt Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott A Hubers
- Division of Clinical Pharmacology, Vanderbilt Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hui Nian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric Grouzmann
- Service de Pharmacologie Clinique, Laboratoire des Catecholamines et Peptides, University Hospital of Lausanne, Lausanne, Switzerland
| | - Philippe J Eugster
- Service de Pharmacologie Clinique, Laboratoire des Catecholamines et Peptides, University Hospital of Lausanne, Lausanne, Switzerland
| | - Dustin S Mayfield
- Division of Clinical Pharmacology, Vanderbilt Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nancy J Brown
- Division of Clinical Pharmacology, Vanderbilt Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
17
|
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).
Collapse
|
18
|
Abstract
There remains an ongoing controversy regarding the safety of dipeptidyl peptidase-4 (DPP-4) inhibitors and the risk of developing heart failure (HF). In addition, none of the animal studies suggested a mechanism for the DPP-4 inhibitors and HF risk. To date, advances in pharmacogenomics have enabled the identification of genetic variants in DPP-4 gene. Studies have shown that genetic polymorphisms in the gene encoding DPP-4 may be associated with potential pathways involved in HF risk. This review discusses the contradictory findings of DPP-4 inhibitors and HF and a potential role for pharmacogenomics. Pharmacogenomics of DPP-4 inhibitors is promising, and genetic information from randomized control trials is urgently needed to gain a full understanding of the safety of DPP-4 inhibitors and the risk of HF.
Collapse
|
19
|
Echouffo-Tcheugui JB, Sheng S, DeVore AD, Matsouaka RA, Hernandez AF, Yancy CW, Heidenreich PA, Bhatt DL, Fonarow GC. Glycated Hemoglobin and Outcomes of Heart Failure (from Get With the Guidelines-Heart Failure). Am J Cardiol 2019; 123:618-626. [PMID: 30553509 DOI: 10.1016/j.amjcard.2018.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 11/10/2018] [Accepted: 11/15/2018] [Indexed: 12/17/2022]
Abstract
Glycated hemoglobin (HbA1C) is a risk factor for new onset heart failure (HF). There is however a paucity of data evaluating its association with outcomes in patients with established HF. We assessed the relation of HbA1C with outcomes among hospitalized HF patients. Among 41,776 HF patients from 263 hospitals participating to the Get with the Guidelines-HF registry between January 2009 and March 2016, we related HbA1C to outcomes (in-hospital mortality, length of hospital stay, discharge to home, 30-day mortality, 30-day readmission, and 1-year mortality), using generalized estimating equation to account for within-hospital clustering and potential confounders. There were 68% of HF patients with diabetes and median HbA1C was 7.1%. Each percent change in HbA1C was associated with higher odds of discharge to home for HbA1C levels <6.5% (covariate-adjusted odds ratio [OR] 1.13 [95% confidence interval 1.04 to 1.12]) or ≥6.5% (OR 1.05 [1.02 to 1.07]). After stratification by diabetes status, this association remained significant only among patients with diabetes (ORs for HbA1C levels <6.5%: 1.17 [1.07 to 1.27]; and ≥6.5%: 1.06 [1.03 to 1.09]). Compared with the lowest HbA1C tertile (HbA1C ≤6.1%), patients in the highest HbA1C tertile (HbA1C 7.3% to 19%) were more likely to have a length of hospital stay >4 days (OR 1.10 [1.02 to 1.18]) and to be discharged home (OR 1.23 [1.14 to 1.33]). There were no significant association between HbA1C and the following outcomes: in-hospital mortality, 30-day mortality, 30-day readmission, and 1-year mortality. In conclusion, among hospitalized HF patients, HbA1C was associated with prolonged hospital stay and home discharge, but not with readmission, short-term, or intermediate-term mortality.
Collapse
|
20
|
Yi H, Lee JH, Shin JY. Signal Detection for Cardiovascular Adverse Events of DPP-4 Inhibitors Using the Korea Adverse Event Reporting System Database, 2008-2016. Yonsei Med J 2019; 60:200-207. [PMID: 30666842 PMCID: PMC6342716 DOI: 10.3349/ymj.2019.60.2.200] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 11/18/2018] [Accepted: 12/20/2018] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Cardiovascular adverse events (AEs) after use of dipeptidyl peptidase-4 (DPP4) inhibitors have been reported and suspected since the launch of DPP-4 inhibitors in 2006. However, few studies have investigated the association between cardiovascular AEs and DPP-4 inhibitors. The objective of this study is to detect the signals of cardiovascular AEs after use of DPP-4 inhibitors by analyzing the Korea Institute of Drug Safety & Risk Management-Korea Adverse Event Reporting System Database (KIDS-KD). MATERIALS AND METHODS Data on the use of oral antidiabetic drugs from 2008 to 2016 were extracted from KIDS-KD, and analyzed descriptively. Data mining was conducted by calculating three indices, which were proportional reporting ratios, reporting odds ratios, and information components, to detect signals from use of all oral antidiabetic drugs including DPP-4 inhibitors. Then, the suspected adverse drug reactions (ADRs) were confirmed by signal detection, and drug label information between the Korea Ministry of Food and Drug Safety and the U.S. Food and Drug Administration were compared. RESULTS Cardiovascular AEs after taking DPP-4 inhibitors were detected in only three (1.0%) out of a total of 307 AE reports. Two of the three cardiovascular AEs were reported after using sitagliptin and one using gemiglipitin, but these were not statistically significant. CONCLUSION Analysis of spontaneous ADR reports data on the use of DPP-4 inhibitors could not showed the association between DPP-4 inhibitors and cardiovascular AEs, due to a small number of cardiovascular AEs reports.
Collapse
Affiliation(s)
- Hyemin Yi
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea
| | - Ji Ho Lee
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea
- National Institute of Food and Drug Safety Evaluation, Korea Ministry of Food and Drug Safety, Cheongju, Korea
| | - Ju Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea.
| |
Collapse
|
21
|
Cheng JWM, Colucci VJ, Kalus JS, Spinler SA. Managing Diabetes and Preventing Heart Disease: Have We Found a Safe and Effective Agent? Ann Pharmacother 2018; 53:510-522. [PMID: 30516068 DOI: 10.1177/1060028018816466] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE While improving glycemic control with antihyperglycemics has been demonstrated to reduce microvascular complications, the benefits of reduction in cardiovascular diseases (CVDs) have not been demonstrated with older agents. This article reviews current evidence of the CV outcomes of newer antihyperglycemics approved since 2008. DATA SOURCES Peer-reviewed articles were identified from MEDLINE (1966 to October 31, 2018) using search terms exenatide, liraglutide, lixisenatide, dulaglutide, semaglutide, alogliptin, linagliptin, saxagliptin, sitagliptin, canagliflozin, dapagliflozin, empagliflozin, mortality, myocardial infarction (MI), heart failure (HF), and stroke. STUDY SELECTION AND DATA EXTRACTION A total of 12 pertinent double-blinded randomized controlled trials were included. DATA SYNTHESIS Liraglutide, empagliflozin, and canagliflozin have been shown in patients with CV diseases and high risk of developing CV disease to be superior to placebo in improving CV outcomes. Saxagliptin and alogliptin have both been demonstrated to increase HF hospitalization, whereas sitagliptin has not. Relevance to Patient Care and Clinical Practice: In contrast to older-generation antihyperglycemics, selected new antihyperglycemic agents have been shown to be superior to placebo in improving CV outcomes. Clinicians may now be able to provide high-risk patients agents that not only help in providing glycemic control, but also prevent both macrovascular and microvascular complications. CONCLUSION Liraglutide, empagliflozin, and canagliflozin have been shown to be superior to placebo in improving CV outcomes. However, there are differences among agents in terms of HF and peripheral arterial disease outcomes. Future studies should focus on evaluating other clinical CV outcomes in patients without existing CVD and perhaps single drug regimens for diabetes.
Collapse
Affiliation(s)
| | | | | | - Sarah A Spinler
- 4 Philadelphia College of Pharmacy, Philadelphia, PA, USA.,5 Binghamton University, Binghamton NY, USA
| |
Collapse
|
22
|
Santucci C, Franchi M, Staszewsky L, La Vecchia C, Latini R, Merlino L, Corrao G, Bosetti C. Incretin-based drugs and hospitalization for heart failure in the clinical practice: A nested case-control study. Diabetes Res Clin Pract 2018; 146:172-179. [PMID: 30332619 DOI: 10.1016/j.diabres.2018.10.006] [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: 07/05/2018] [Revised: 10/01/2018] [Accepted: 10/11/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS There are concerns that incretin-based antidiabetic drugs - including dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists - increase the risk of hospitalization for heart failure (HF). To further analyse this issue, we conducted a nested case-control study within a cohort of antidiabetic users in a real world setting. METHODS AND RESULTS Within a cohort of 133,639 subjects with a first prescription of an antidiabetic drug (new-users) between 2010 and 2016 in Lombardy, Italy, and were followed-up to 2016, we identified 4057 subjects with a first hospitalization for HF and 80,450 controls matched on sex, age, and date of cohort-entry. The multivariate odds ratios (ORs) of HF in relation to current use of incretin-based drugs as compared to current use of two or more oral antidiabetics was 1.06 (95% confidence interval, CI, 0.83-1.35), with no evidence of a trend in risk with increasing duration of use. The corresponding ORs were 1.10 (95% CI 0.85-1.41) for DPP-4 inhibitors and 0.84 (95% CI 0.48-1.47) for GLP-1 receptor agonists. Estimates were consistent in various sensitivity analyses. CONCLUSIONS This study indicates that incretin-based drugs are not associated with an increased risk of hospitalization for HF, thus providing further reassurance on the cardiovascular safety of these antidiabetic drugs in the clinical practice.
Collapse
Affiliation(s)
- C Santucci
- Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - M Franchi
- National Centre for Healthcare Research & Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy; Laboratory of Healthcare Research & Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - L Staszewsky
- Department of Cardiovascular Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - C La Vecchia
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - R Latini
- Department of Cardiovascular Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - L Merlino
- Unità Organizzativa Governo dei Dati, delle Strategie e Piani del Sistema Sanitario, Regione Lombardia, Milan, Italy
| | - G Corrao
- National Centre for Healthcare Research & Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy; Laboratory of Healthcare Research & Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - C Bosetti
- Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.
| |
Collapse
|
23
|
Weir DL, Abrahamowicz M, Beauchamp ME, Eurich DT. Acute vs cumulative benefits of metformin use in patients with type 2 diabetes and heart failure. Diabetes Obes Metab 2018; 20:2653-2660. [PMID: 29934961 DOI: 10.1111/dom.13448] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/06/2018] [Accepted: 06/19/2018] [Indexed: 12/28/2022]
Abstract
AIMS To evaluate the association between metformin use and heart failure (HF) exacerbation in people with type 2 diabetes (T2D) and pre-existing HF using alternative exposure models. MATERIALS AND METHODS We analysed data for patients with T2D and incident HF from a national US insurance claims database. We compared the results of several multivariable Cox models where time-varying use of metformin was modelled as: (1) current use; (2) total duration of past use; and (3) use within the past 30 days or 10 days. The outcome was defined as time to HF-related hospitalization. We then re-analysed the data using flexible weighted cumulative exposure (WCE) models. RESULTS A total of 7620 patients with diabetes and incident HF were analysed. The mean (SD) patient age was 54 (8) years, and 58% (n = 4440) were men. In all, 3799 individuals (50%) were exposed to metformin, and 837 HF hospitalizations (11%) occurred (mean follow-up 1.7 years). Results of conventional models suggested potential acute benefits in reducing HF exacerbation with metformin use in the past 10 days (adjusted hazard ratio [aHR] 0.76, 95% confidence interval [CI] 0.60-0.97), while WCE models, which provided a better fit for the data, suggested lack of a systematic effect (aHR 0.91, 95% CI 0.69-1.20). CONCLUSIONS Our results suggest that cumulative metformin exposure does not decrease the risk of HF-related exacerbation. Use of other anti-hyperglycaemic agents with proven efficacy in patients with HF should also be considered as treatment options in this population.
Collapse
Affiliation(s)
- Daniala L Weir
- Clinical and Health Informatics Research Group, Department of Medicine, McGill University, Montreal, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- Centre for Health Outcomes Research, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Marie-Eve Beauchamp
- Centre for Health Outcomes Research, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, Canada
- Alliance for Canadian Health Outcomes Research in Diabetes, University of Alberta, Edmonton, Canada
| |
Collapse
|
24
|
Uncoupling proteins as a therapeutic target to protect the diabetic heart. Pharmacol Res 2018; 137:11-24. [PMID: 30223086 DOI: 10.1016/j.phrs.2018.09.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/07/2018] [Accepted: 09/13/2018] [Indexed: 12/16/2022]
Abstract
Myocardial remodeling and dysfunction caused by accelerated oxidative damage is a widely reported phenomenon within a diabetic state. Altered myocardial substrate preference appears to be the major cause of enhanced oxidative stress-mediated cell injury within a diabetic heart. During this process, exacerbated free fatty acid flux causes an abnormal increase in mitochondrial membrane potential leading to the overproduction of free radical species and subsequent cell damage. Uncoupling proteins (UCPs) are expressed within the myocardium and can protect against free radical damage by modulating mitochondrial respiration, leading to reduced production of reactive oxygen species. Moreover, transgenic animals lacking UCPs have been shown to be more susceptible to oxidative damage and display reduced cardiac function when compared to wild type animals. This suggests that tight regulation of UCPs is necessary for normal cardiac function and in the prevention of diabetes-induced oxidative damage. This review aims to enhance our understanding of the pathophysiological mechanisms relating to the role of UCPs in a diabetic heart, and further discuss known pharmacological compounds and hormones that can protect a diabetic heart through the modulation of UCPs.
Collapse
|
25
|
Hubers SA, Wilson JR, Yu C, Nian H, Grouzmann E, Eugster P, Shibao CA, Billings FT, Kerman SJ, Brown NJ. DPP (Dipeptidyl Peptidase)-4 Inhibition Potentiates the Vasoconstrictor Response to NPY (Neuropeptide Y) in Humans During Renin-Angiotensin-Aldosterone System Inhibition. Hypertension 2018; 72:712-719. [PMID: 29987109 PMCID: PMC6202157 DOI: 10.1161/hypertensionaha.118.11498] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 06/11/2018] [Indexed: 01/01/2023]
Abstract
DPP (dipeptidyl peptidase)-4 inhibitors are antidiabetic drugs that may increase heart failure in high-risk patients. NPY (neuropeptide Y) is coreleased with norepinephrine, causes vasoconstriction via the Y1 receptor, and is degraded by DPP4 to NPY (3-36) in vitro. NPY (3-36) decreases release of norepinephrine via the Y2 receptor. We tested the hypothesis that DPP4 inhibition would potentiate the vasoconstrictor effect of NPY. Eighteen nonsmokers (12 healthy controls and 6 with type 2 diabetes mellitus) participated in 1 of 2 randomized, double-blind, placebo-controlled crossover studies. First, subjects were randomized to order of treatment with sitagliptin 100 mg/d versus placebo for 7 days separated by 4-week washout. On the last day of treatment, NPY was infused by brachial artery and forearm blood flow was measured using plethysmography. Blood samples were collected after each dose. NPY infusions were repeated after 90-minute washout and intra-arterial enalaprilat. Second, 5 healthy subjects were randomized to crossover treatment with sitagliptin 100 mg/d plus valsartan 160 mg/d versus placebo plus valsartan. NPY infusions were performed on the seventh day of treatment. NPY caused dose-dependent vasoconstriction. During enalaprilat, sitagliptin significantly potentiated NPY-induced vasoconstriction in controls and diabetics ( P≤0.02 for forearm blood flow in either group). Baseline norepinephrine release was increased during sitagliptin and enalaprilat, but not further by NPY. Sitagliptin increased the ratio of NPY to NPY (3-36). During valsartan, sitagliptin also significantly potentiated NPY-induced vasoconstriction ( P=0.009 for forearm blood flow). Potentiation of endogenous NPY could contribute to cardiovascular effects of DPP4 inhibitors in patients taking an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker.
Collapse
Affiliation(s)
- Scott A. Hubers
- Division of Clinical Pharmacology, Vanderbilt University Medical Center Department of Medicine
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Jessica R. Wilson
- Division of Clinical Pharmacology, Vanderbilt University Medical Center Department of Medicine
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Pennsylvania
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center
| | - Hui Nian
- Department of Biostatistics, Vanderbilt University Medical Center
| | - Eric Grouzmann
- Service de Pharmacologie Clinique, Laboratoire des Catécholamines et Peptides, University Hospital of Lausanne
| | - Philippe Eugster
- Service de Pharmacologie Clinique, Laboratoire des Catécholamines et Peptides, University Hospital of Lausanne
| | - Cyndya A. Shibao
- Division of Clinical Pharmacology, Vanderbilt University Medical Center Department of Medicine
| | | | - Scott Jafarian Kerman
- Division of Clinical Pharmacology, Vanderbilt University Medical Center Department of Medicine
| | - Nancy J. Brown
- Division of Clinical Pharmacology, Vanderbilt University Medical Center Department of Medicine
| |
Collapse
|
26
|
Noels H, Theelen W, Sternkopf M, Jankowski V, Moellmann J, Kraemer S, Lehrke M, Marx N, Martin L, Marx G, Jankowski J, Goetzenich A, Stoppe C. Reduced post-operative DPP4 activity associated with worse patient outcome after cardiac surgery. Sci Rep 2018; 8:11820. [PMID: 30087386 PMCID: PMC6081383 DOI: 10.1038/s41598-018-30235-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/19/2018] [Indexed: 01/04/2023] Open
Abstract
Cardiac surgery with cardiopulmonary bypass (CPB) triggers myocardial ischemia/reperfusion injury contributing to organ dysfunction. Preclinical studies revealed that dipeptidyl peptidase (DPP4) inhibition is protective during myocardial infarction. Here, we assessed for the first time the relation of peri-operative DPP4-activity in serum of 46 patients undergoing cardiac surgery with patients' post-operative organ dysfunction during intensive care unit (ICU) stay. Whereas a prior myocardial infarction significantly reduced pre-operative DDP4-activity, patients with preserved left ventricular function showed an intra-operative decrease of DPP4-activity. The latter correlated with aortic cross clamping time, indicative for the duration of surgery-induced myocardial ischemia. As underlying mechanism, mass-spectrometry revealed increased DPP4 oxidation by cardiac surgery, with DPP4 oxidation reducing DPP4-activity in vitro. Further, post-operative DPP4-activity was negatively correlated with the extent of post-operative organ injury as measured by SAPS II and SOFA scoring, circulating levels of creatinine and lactate, as well as patients' stay on the ICU. In conclusion, cardiac surgery reduces DPP4-activity through oxidation, with low post-operative DPP4-activity being associated with organ dysfunction and worse outcome of patients during the post-operative ICU stay. This likely reflects the severity of myocardial ischemia/reperfusion injury and may suggest potential beneficial effects of anti-oxidative treatments during cardiac surgery.
Collapse
Affiliation(s)
- Heidi Noels
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital Aachen, RWTH Aachen University, Aachen, Germany.
| | - Wendy Theelen
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Marieke Sternkopf
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Vera Jankowski
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Julia Moellmann
- Department of Internal Medicine I-Cardiology, University Hospital Aachen, Aachen, Germany
| | - Sandra Kraemer
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Michael Lehrke
- Department of Internal Medicine I-Cardiology, University Hospital Aachen, Aachen, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I-Cardiology, University Hospital Aachen, Aachen, Germany
| | - Lukas Martin
- Department of Intensive Care Medicine, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Joachim Jankowski
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital Aachen, RWTH Aachen University, Aachen, Germany.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Andreas Goetzenich
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine, University Hospital, RWTH Aachen University, Aachen, Germany.
| |
Collapse
|
27
|
Avogaro A, Fadini GP. The pleiotropic cardiovascular effects of dipeptidyl peptidase-4 inhibitors. Br J Clin Pharmacol 2018; 84:1686-1695. [PMID: 29667232 DOI: 10.1111/bcp.13611] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 04/09/2018] [Accepted: 04/10/2018] [Indexed: 12/12/2022] Open
Abstract
Patients with Type 2 diabetes have an excess risk for cardiovascular disease. One of the several approaches, included in the guidelines for the management of Type 2 diabetes, is based on dipeptidyl peptidase 4 (DPP-4; also termed CD26) inhibitors, also called gliptins. Gliptins inhibit the degradation of glucagon-like peptide-1 (GLP-1): this effect is associated with increased circulating insulin-to-glucagon ratio, and a consequent reduction of HbA1c. In addition to incretin hormones, there are several proteins that may be affected by DPP-4 and its inhibition: among these some are relevant for the cardiovascular system homeostasis such as SDF-1α and its receptor CXCR4, brain natriuretic peptides, neuropeptide Y and peptide YY. In this review, we will discuss the pathophysiological relevance of gliptin pleiotropism and its translational potential.
Collapse
Affiliation(s)
- Angelo Avogaro
- Department of Medicine, Section of Diabetes and Metabolic Diseases, University of Padova, Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, Section of Diabetes and Metabolic Diseases, University of Padova, Padova, Italy
| |
Collapse
|
28
|
Tseng CH. Sitagliptin and heart failure hospitalization in patients with type 2 diabetes. Oncotarget 2018; 7:62687-62696. [PMID: 27409676 PMCID: PMC5308758 DOI: 10.18632/oncotarget.10507] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 06/17/2016] [Indexed: 01/21/2023] Open
Abstract
This study evaluated the risk of heart failure hospitalization in a 1:1 matched pair sample of sitagliptin ever and never users derived from the Taiwan's National Health Insurance. A total of 85,859 ever users and 85,859 never users matched on 8 digits of propensity score were followed for the first event of heart failure hospitalization until December 31, 2011. The treatment effect (for ever versus never users, and for tertiles of cumulative duration of therapy) was estimated by Cox regression incorporated with the inverse probability of treatment weighting using propensity score. Additionally, adjusted hazard ratios for heart failure were estimated for the baseline characteristics in sitagliptin ever users. Results showed that the incidence of heart failure hospitalization was 1,020.16 and 832.54 per 100,000 person-years, respectively, for ever and never users, with an overall hazard ratio (95% confidence intervals) of 1.262 (1.167-1.364). While compared to never users, the respective hazard ratio for the first, second, and third tertile of cumulative duration < 3.7, 3.7-10.3 and >10.3 months was 2.721 (2.449-3.023), 1.472 (1.318-1.645) and 0.515 (0.447-0.594). Older age, longer diabetes duration, male sex, and use of insulin, sulfonylurea, calcium channel blockers, aspirin, ticlopidine, clopidogrel and dipyridamole were significantly associated with a higher risk in sitagliptin users, but dyslipidemia and use of metformin and statin were protective. In conclusion, sitagliptin increases the risk of heart failure hospitalization within one year of its use, but reduces the risk thereafter. Some factors predisposing to sitagliptin-related heart failure are worthy of attention in clinical practice.
Collapse
Affiliation(s)
- Chin-Hsiao Tseng
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Division of Environmental Health and Occupational Medicine of the National Health Research Institutes, Zhunan, Taiwan
| |
Collapse
|
29
|
Veeranki S, Tyagi SC. Mdivi-1 induced acute changes in the angiogenic profile after ischemia-reperfusion injury in female mice. Physiol Rep 2018; 5:5/11/e13298. [PMID: 28576854 PMCID: PMC5471437 DOI: 10.14814/phy2.13298] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/03/2017] [Accepted: 05/04/2017] [Indexed: 01/04/2023] Open
Abstract
The aim of this study is to determine the effects of mitochondrial division inhibitor 1 (Mdivi‐1), the mitochondrial fission inhibitor, on the angiogenic profiles after the ischemia reperfusion injury (IR injury) in female mice. Female mice were treated with Mdivi‐1 inhibitor, 2 days prior, on the day of IR injury and 2 days after IR injury, for a period of 5 days. Both control and treatment groups underwent 30 min of ischemia and 72 h of reperfusion. On the day 3, mice were sacrificed and the ischemic and nonischemic portions of heart tissue were collected. Relative levels of 53 angiogenesis‐related proteins were quantified simultaneously using Angiogenic arrays. Heart function was evaluated before and after 72 h of IR injury. Mdivi‐1 treatment ameliorated IR induced functional deterioration with positive angiogenic profile. The seminal changes include suppression of Matrix metalloproteinase (MMP3), tissue inhibitor of metalloproteases (TIMP1) and chemokine (C‐X‐C motif) ligand 10 (CXCL10) levels and prevention of connexin 43 (Cx43) loss and downregulation in the antioxidant enzyme levels. These changes are correlated with enhanced endothelial progenitor cell marker (cluster of differentiation (CD31), endothelial‐specific receptor tyrosine kinase (Tek), fMS‐like tyrosine kinase 4 (Flt4) and kinase insert domain protein receptor (Kdr)) presence. Our study is the first to report the role of mitochondrial dynamics in regulation of myocardial IR‐induced angiogenic responses. Inhibition of excessive mitochondrial fission after IR injury ameliorated heart dysfunction and conferred positive angiogenic response. In addition, there were improvements in the preservation of Cx43 levels and oxidative stress handling along with suppression of apoptosis activation. The findings will aid in shaping the rational drug development process for the prevention of ischemic heart disease, especially in females.
Collapse
Affiliation(s)
- Sudhakar Veeranki
- Department of Physiology and Biophysics, University of Louisville School of Medicine, Louisville, Kentucky, 40202
| | - Suresh C Tyagi
- Department of Physiology and Biophysics, University of Louisville School of Medicine, Louisville, Kentucky, 40202
| |
Collapse
|
30
|
Abstract
INTRODUCTION Dipeptidyl peptidase-4 inhibitors (DPP-4is) are generally considered as glucose-lowering agents with a safe profile in type 2 diabetes. AREAS COVERED An updated review of recent safety data from randomised controlled trials, observational studies, meta-analyses, pharmacovigilance reports regarding alogliptin, linagliptin, saxagliptin, sitagliptin, and vildagliptin, with a special focus on risks of hypoglycemia, pancreatitis and pancreatic cancer, major cardiovascular events, hospitalisation for heart failure and other new safety issues, such as bone fractures and arthralgia. The safety of DPP-4i use in special populations, elderly patients, patients with renal impairment, liver disease or heart failure, will also be discussed. EXPERT OPINION The good tolerance/safety profile of DPP-4is has been largely confirmed, including in more fragile populations, with no gastrointestinal adverse effects and a minimal risk of hypoglycemia. DPP-4is appear to be associated with a small increased incidence of acute pancreatitis in placebo-controlled trials, although most observational studies are reassuring. Most recent studies with DPP-4is do not confirm the increased risk of hospitalisation for heart failure reported with saxagliptin in SAVOR-TIMI 53, but further post-marketing surveillance is still recommended. New adverse events have been reported such as arthralgia, yet a causal relationship remains unclear.
Collapse
Affiliation(s)
- André Jacques Scheen
- a Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine , CHU Sart Tilman, University of Liège , Liège , Belgium.,b Division of Clinical Pharmacology , Center for Interdisciplinary Research on Medicines (CIRM) , Liège , Belgium
| |
Collapse
|
31
|
Dipeptidyl Peptidase-4 Inhibitors and Heart Failure Exacerbation in the Veteran Population: An Observational Study. Pharmacotherapy 2018; 38:334-340. [DOI: 10.1002/phar.2085] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
32
|
Umpierrez GE, Bailey TS, Carcia D, Shaefer C, Shubrook JH, Skolnik N. Improving postprandial hyperglycemia in patients with type 2 diabetes already on basal insulin therapy: Review of current strategies. J Diabetes 2018; 10:94-111. [PMID: 28581207 DOI: 10.1111/1753-0407.12576] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 05/02/2017] [Accepted: 05/21/2017] [Indexed: 11/28/2022] Open
Abstract
A large number of patients with type 2 diabetes (T2D) on basal insulin do not reach their HbA1c goals and require additional therapy to address postprandial hyperglycemia. Guidelines from expert bodies have outlined several approaches to accomplish postprandial glucose (PPG) control, and recent literature suggests several more. This article provides strategies for primary care physicians caring for patients with T2D who do not achieve glycemic control with basal insulin alone. Current treatment guidelines and strategies for improving PPG control are reviewed, including the efficacy, safety, and cost-effectiveness of rapid-acting insulin (RAI) analogs, premixed insulin, glucagon-like peptide-1 (GLP-1) receptor agonists (RAs), dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors, and α-glucosidase inhibitors. Other approaches, such as combinations of newer basal insulin plus RAI and a fixed-ratio combination of basal insulin and a GLP-1 RA, are also described.
Collapse
Affiliation(s)
| | | | - Danielle Carcia
- Abington Hospital Jefferson Health, Abington, Pennsylvania, USA
| | | | | | - Neil Skolnik
- Abington Hospital Jefferson Health, Abington, Pennsylvania, USA
| |
Collapse
|
33
|
Sharma M, Beckley N, Nazareth I, Petersen I. Effectiveness of sitagliptin compared to sulfonylureas for type 2 diabetes mellitus inadequately controlled on metformin: a systematic review and meta-analysis. BMJ Open 2017; 7:e017260. [PMID: 29084794 PMCID: PMC5665259 DOI: 10.1136/bmjopen-2017-017260] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 07/10/2017] [Accepted: 07/12/2017] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To assess the effectiveness of sitagliptin compared to sulfonylureas as add-on to metformin in adults with type 2 diabetes mellitus from both randomised controlled trials (RCTs) and 'real-world' non-randomised studies. METHODS AND ANALYSES We conducted a systematic review of EMBASE, MEDLINE, CENTRAL and grey literature for RCTs and non-randomised studies. We reported outcomes relating to change in HbA1c, fasting glucose, weight, blood pressure and lipids from baseline and need for treatment change. No study investigating macrovascular and microvascular diabetes complications was found. Meta-analysis was used where studies were sufficiently homogenous. RESULTS Seven RCTs and five non-randomised studies were eligible for inclusion from 1335 articles retrieved. Meta-analysis of three homogenous RCTs revealed a statistically significant decrease in weight with sitagliptin when compared to sulfonylureas (weighted mean difference (WMD) -2.05 kg; 95% CI -2.38 to -1.71); however, a similar change from baseline in HbA1c (WMD 0.05; 95% CI -0.03 to 0.12), fasting glucose (WMD 0.11; 95% CI -0.08 to -0.29), blood pressure, lipids and the proportion achieving HbA1c <7% by study end (OR 0.98; 95% CI 0.85 to 1.13) was observed.Non-randomised studies identified consisted of four prospective and one retrospective cohort study. Three of these five studies were of moderate/high quality, and results though less precise suggested similar real-world comparative glycaemic and weight effectiveness for both treatments. Data from two cohort studies suggested that treatment change (HR 0.65; 95% CI 0.57 to 0.73) and insulin initiation (HR 0.76; 95% CI 0.65 to 0.90) were less likely among those prescribed sitagliptin; however, inadequate reporting of HbA1c at time of treatment change made interpreting results challenging. CONCLUSION Sitagliptin users experienced modest weight loss compared to gain with sulfonylureas; however, this difference was around 2 kg, which may not be of major clinical significance for most individuals. Similar change was observed across most other effectiveness outcomes reported. Further studies are needed to address longer-term effectiveness outcomes for sitagliptin compared to sulfonylureas as add-on to metformin. PROSPERO REGISTRATION NUMBER CRD42016033983.
Collapse
Affiliation(s)
- Manuj Sharma
- Department of Primary Care and Population Health, University College London, London, UK
| | - Nicholas Beckley
- Department of Primary Care and Population Health, University College London, London, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London, London, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| |
Collapse
|
34
|
Schott G, Martinez YV, Ediriweera de Silva RE, Renom-Guiteras A, Vögele A, Reeves D, Kunnamo I, Marttila-Vaara M, Sönnichsen A. Effectiveness and safety of dipeptidyl peptidase 4 inhibitors in the management of type 2 diabetes in older adults: a systematic review and development of recommendations to reduce inappropriate prescribing. BMC Geriatr 2017; 17:226. [PMID: 29047372 PMCID: PMC5647559 DOI: 10.1186/s12877-017-0571-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Preventable drug-related hospital admissions can be associated with drugs used in diabetes and the benefits of strict diabetes control may not outweigh the risks, especially in older populations. The aim of this study was to look for evidence on risks and benefits of DPP-4 inhibitors in older adults and to use this evidence to develop recommendations for the electronic decision support tool of the PRIMA-eDS project. Methods Systematic review using a staged approach which searches for systematic reviews and meta-analyses first, then individual studies only if prior searches were inconclusive. The target population were older people (≥65 years old) with type 2 diabetes. We included studies reporting on the efficacy and/or safety of DPP-4 inhibitors for the management of type 2 diabetes. Studies were included irrespective of DPP-4 inhibitors prescribed as monotherapy or in combination with any other drug for the treatment of type 2 diabetes. The target intervention was DPP-4 inhibitors compared to placebo, no treatment, other drugs to treat type 2 diabetes or a non-pharmacological intervention. Results Thirty studies (reported in 33 publications) were included: 1 meta-analysis, 17 intervention studies and 12 observational studies. Sixteen studies were focused on older adults and 14 studies reported subgroup analyses in participants ≥65, ≥70, or ≥75 years. Comorbidities were reported by 26 studies and frailty or functional status by one study. There were conflicting findings regarding the effectiveness of DPP-4 inhibitors in older adults. In general, DPP-4 inhibitors showed similar or better safety than placebo and other antidiabetic drugs. However, these safety data are mainly based on short-term outcomes like hypoglycaemia in studies with HbA1c control levels recommended for younger people. One recommendation was developed advising clinicians to reconsider the use of DPP-4 inhibitors for the management of type 2 diabetes in older adults with HbA1c <8.5% because of scarce data on clinically relevant benefits of their use. Twenty-two of the included studies were funded by pharmaceutical companies and authored or co-authored by employees of the sponsor. Conclusions Other than the surrogate endpoint of improved glycaemic control, data on clinically relevant benefits of DPP-4 inhibitors in the treatment of type 2 diabetes mellitus in older adults is scarce. DPP-4 inhibitors might have a lower risk of hypoglycaemia compared to other antidiabetic drugs but data show conflicting findings for long-term benefits. Further studies are needed that evaluate the risks and benefits of DPP-4 inhibitors for the management of type 2 diabetes mellitus in older adults, using clinically relevant outcomes and including representative samples of older adults with information on their frailty status and comorbidities. Studies are also needed that are independent of pharmaceutical company involvement. Electronic supplementary material The online version of this article (doi:10.1186/s12877-017-0571-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Gisela Schott
- Drug Commission of the German Medical Association, Berlin, Germany.
| | - Yolanda V Martinez
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, England
| | - R Erandie Ediriweera de Silva
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, England.,Family Medicine Unit, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Anna Renom-Guiteras
- Institute of General Practice and Family Medicine, Witten/Herdecke University, Witten, Germany.,Department of Geriatrics, University Hospital Parc de Salut Mar, Barcelona, Spain
| | - Anna Vögele
- South Tyrolean Academy of General Practice, Bolzano, Italy
| | - David Reeves
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, England
| | - Ilkka Kunnamo
- Duodecim Medical Publications Ltd, Helsinki, Finland
| | | | - Andreas Sönnichsen
- Institute of General Practice and Family Medicine, Witten/Herdecke University, Witten, Germany
| |
Collapse
|
35
|
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.
Collapse
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.).
| |
Collapse
|
36
|
Gokhale M, Buse JB, Jonsson Funk M, Lund J, Pate V, Simpson RJ, Stürmer T. No increased risk of cardiovascular events in older adults initiating dipeptidyl peptidase-4 inhibitors vs therapeutic alternatives. Diabetes Obes Metab 2017; 19:970-978. [PMID: 28195389 PMCID: PMC5471114 DOI: 10.1111/dom.12906] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 02/08/2017] [Accepted: 02/08/2017] [Indexed: 01/02/2023]
Abstract
AIM To compare the cardiovascular (CV) risk associated with dipeptidyl peptidase-4 (DPP-4) inhibitors relative to sulphonylureas (SUs) and thiazolidinediones (TZDs). METHODS During 2007 to 2013, using Medicare data for beneficiaries aged >65 years, we identified the following 2 cohorts of new-users, who had not been exposed to the drugs being compared in the 6 months before initiation: (1) DPP-4 inhibitor vs SU initiators and (2) DPP-4 inhibitor vs TZD initiators. Using propensity-score-adjusted Cox models accounting for competing risk by death, we estimated the hazard ratios (HRs), risk differences and 95% confidence intervals (CIs) for myocardial infarction (MI), stroke, hospitalization for heart failure (HF), and a combined outcome (MI, stroke, all-cause mortality). RESULTS In the DPP-4 inhibitor vs SU comparison, there were 30 130 DPP-4 inhibitor initiators and 68 382 SU initiators. Their mean age was 75 years, 41% were men and 55% had a baseline CV condition. The HR for the composite outcome was 0.75 (95% CI 0.72-0.79) over a median treatment duration of 1 year, but the 1-year risks of MI were 1.00 (95% CI 0.89-1.12) and 1.47 (95% CI 1.38-1.56) per 100 patients for DPP-4 inhibitors and SUs, respectively, and the corresponding stroke risks were 0.98 (95% CI 0.87-1.10) and 1.09 (95% CI 1.01-1.17). For the DPP-4 inhibitor vs TZD comparison, there were 20 596 DPP-4 inhibitor initiators and 13 526 TZD initiators without previous HF. Their mean age was 74 years, 42% were men and 30% had a baseline CV event. The composite outcome HR was 0.94 (95% CI 0.86-1.02) over a median treatment duration of 1 year. The 1-year risk for MI was ~0.90 and for stroke it was ~0.80 per 100 patients in both DPP-4 inhibitor and TZD initiators. CONCLUSION Although limited by the short treatment period, the present study suggests there is no increased short-term risk of MI, stroke or HF with DPP-4 inhibitors vs SUs/TZDs.
Collapse
Affiliation(s)
- Mugdha Gokhale
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
- Real World Evidence, GlaxoSmithKline, Collegeville,USA
| | - John B. Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, USA
| | - Michele Jonsson Funk
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | - Jennifer Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | - Ross J Simpson
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, USA
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| |
Collapse
|
37
|
Liu J, Li L, Deng K, Xu C, Busse JW, Vandvik PO, Li S, Guyatt GH, Sun X. Incretin based treatments and mortality in patients with type 2 diabetes: systematic review and meta-analysis. BMJ 2017; 357:j2499. [PMID: 28596247 PMCID: PMC5463186 DOI: 10.1136/bmj.j2499] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective To assess the impact of incretin based treatment on all cause mortality in patients with type 2 diabetes.Design Systematic review and meta-analysis of randomised trials.Data sources Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov.Eligibility criteria Randomised controlled trials that compared glucagon-like peptide-1 (GLP-1) receptor agonists or dipeptidyl peptidase-4 (DPP-4) inhibitors with placebo or active anti-diabetic drugs in patients with type 2 diabetes.Data collection and analysis Paired reviewers independently screened citations, assessed risk of bias of included studies, and extracted data. Peto's method was used as the primary approach to pool effect estimates from trials, sensitivity analyses were carried out with other statistical approaches, and meta-regression was applied for six prespecified hypotheses to explore heterogeneity. The GRADE approach was used to rate the quality of evidence.Results 189 randomised controlled trials (n=155 145) were included, all of which were at low to moderate risk of bias; 77 reported no events of death and 112 reported 3888 deaths among 151 614 patients. Meta-analysis of 189 trials showed no difference in all cause mortality between incretin drugs versus control (1925/84 136 v 1963/67 478; odds ratio 0.96, 95% confidence interval 0.90 to 1.02, I2=0%; risk difference 3 fewer events (95% confidence interval 7 fewer to 1 more) per 1000 patients over five years; moderate quality evidence). Results suggested the possibility of a mortality benefit with GLP-1 agonists but not DPP-4 inhibitors, but the subgroup hypothesis had low credibility. Sensitivity analyses showed no important differences in the estimates of effects.Conclusions Current evidence does not support the suggestion that incretin based treatment increases all cause mortality in patients with type 2 diabetes. Further studies are warranted to examine if the effect differs between GLP-1 agonists versus DPP-4 inhibitors.
Collapse
Affiliation(s)
- Jiali Liu
- Chinese Evidence-based Medicine Centre and CREAT Group, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Centre, Chengdu, 610041, Sichuan, China
| | - Ling Li
- Chinese Evidence-based Medicine Centre and CREAT Group, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Centre, Chengdu, 610041, Sichuan, China
| | - Ke Deng
- Chinese Evidence-based Medicine Centre and CREAT Group, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Centre, Chengdu, 610041, Sichuan, China
| | - Chang Xu
- Chinese Evidence-based Medicine Centre and CREAT Group, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Centre, Chengdu, 610041, Sichuan, China
| | - Jason W Busse
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON L8S 4K1, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON L8S 4K1, Canada
- Michael G DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Per Olav Vandvik
- Norwegian Knowledge Centre for the Health Services, N-0130 Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust, 2819 Gjøvik, Norway
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON L8S 4K1, Canada
- Department of Medicine, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Xin Sun
- Chinese Evidence-based Medicine Centre and CREAT Group, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Centre, Chengdu, 610041, Sichuan, China
| |
Collapse
|
38
|
Chin HJ, Nam JH, Lee EK, Shin JY. Comparative safety for cardiovascular outcomes of DPP-4 inhibitors versus glimepiride in patients with type 2 diabetes: A retrospective cohort study. Medicine (Baltimore) 2017; 96:e7213. [PMID: 28640111 PMCID: PMC5484219 DOI: 10.1097/md.0000000000007213] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Concerns about the cardiovascular safety of dipeptidyl peptidase-4 (DPP-4) inhibitors persist. This study sought to determine whether there is a differential risk of hospitalization for cardiovascular diseases (CVDs) between DPP-4 inhibitors and glimepiride.We conducted this retrospective cohort study by using the Korean National Health Insurance Service database from December 1, 2008, to December 31, 2013. The study subjects were new users of DPP-4 inhibitors or glimepiride for type 2 diabetes. Outcome was defined as hospitalization for CVDs, including angina pectoris, myocardial infarction, transient cerebral ischemic attack, heart failure, or cerebrovascular disease or any procedure involving coronary artery bypass grafting or percutaneous coronary intervention. We used a Cox proportional hazard model to estimate the adjusted hazard ratios (aHRs) and their 95% confidence intervals (CIs), to assess the risk of CVDs associated with the use of DPP-4 inhibitors compared with glimepiride.The cohort consisted of 1,045,975 patients, with 6504 in the DPP-4 inhibitors group and 13,447 in the glimepiride group. No significant increased risk of total CVDs was found (aHR, 0.87; 95% CI, 0.75-1.01) in the DPP-4 inhibitors versus glimepiride group. A decreased risk of hospitalization for CVDs was found among patients with a history of visit for CVDs (aHR, 0.73; 95% CI, 0.56-0.97) or with >2.5 years' duration of type 2 diabetes (aHR, 0.77; 95% CI, 0.66-0.91) in the DPP-4 inhibitors versus glimepiride group.DPP-4 inhibitors did not increase cardiovascular risk compared with glimepiride regardless of CVD history and diabetes duration.
Collapse
|
39
|
Weinrauch LA, Segal AR, Bayliss GP, Liu J, Wisniewski E, D'Elia JA. Changes in treatment of hyperglycemia in a hypertensive type 2 diabetes population as renal function declines. Clin Kidney J 2017; 10:661-665. [PMID: 28979777 PMCID: PMC5622897 DOI: 10.1093/ckj/sfx020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 02/27/2017] [Indexed: 11/18/2022] Open
Abstract
Background Cardiovascular complications associated with expensive noninsulin agents for type 2 diabetes are the focus of concern in light of the risk of kidney dysfunction with aging. Head-to-head comparisons are unavailable to guide the choice of new drugs for hyperglycemia in patients with type 2 diabetes, decreased estimated glomerular filtration rate (eGFR) and increased cardiovascular risk. A first approach would be to document current medication choices. Methods All prescriptions for 10 151 patients (5623 males/4528 females) with both type 2 diabetes and hypertension seen two or more times during a 5-year period (2007–12) at Joslin Diabetes Center were evaluated. {mean age 64 years [interquartile range (IQR) 64–65)], body mass index 31 kg/m2 (IQR 30–32) and mean eGFR 78 mL/min/1.73 m2 (IQR 78, 78)}. Results Insulin was used in >60% of patients, metformin in 50% and sulfonylurea derivatives in 25%. Dipeptidyl peptidase 4 (DPP4) and acarbose class drugs were prescribed in 10% of patients, GLP-1 in 8% and other classes [including thiazolidinediones (TZD)] in <5%. Patients were grouped into four drug Categories none, 447 (4%); insulin only, 3836 (38%); other than insulin, 2910 (29%) and insulin combinations, 2955 (29%). Common combinations included insulin/metformin [n = 2493 (25%)], insulin/sulfonylureas [706 (7%)], metformin/sulfonylureas [2017 (20%)], metformin/GLP1 [949 ( 9%)], metformin/DPP4 [895 (9%)] and metformin/TZD [500 (5%)]. Insulin use increased to 70% from 35% as eGFR dropped to <30 mL/min/1.73 m2; use of insulin combined with other drugs dropped to 12% from 31% and the use of other drugs alone without insulin dropped similarly to 12% from 30%. Conclusions Reduced renal function was associated with increased use of insulin and decreased use of other anti-diabetic agents in a statistically significant progression. BMI and gender did not influence medication choice.
Collapse
Affiliation(s)
- Larry A Weinrauch
- Kidney and Hypertension Section, Joslin Diabetes Center, Boston, MA, USA.,Clinical End Points Section, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Alissa R Segal
- Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
| | - George P Bayliss
- Division of Kidney Diseases and Hypertension, Rhode Island Hospital, Alpert Medical School, Brown University, Providence, RI, USA
| | - Jiankang Liu
- Clinical End Points Section, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Eric Wisniewski
- Kidney and Hypertension Section, Joslin Diabetes Center, Boston, MA, USA
| | - John A D'Elia
- Kidney and Hypertension Section, Joslin Diabetes Center, Boston, MA, USA
| |
Collapse
|
40
|
LeBras MH, Barry AR, Koshman SL. Cardiovascular safety outcomes of new antidiabetic therapies. Am J Health Syst Pharm 2017; 74:970-976. [PMID: 28483748 DOI: 10.2146/ajhp160279] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE The cardiovascular safety outcomes of newer antidiabetic agents were reviewed. SUMMARY Seven randomized, placebo-controlled trials involving patients with type 2 diabetes mellitus with or at risk for cardiovascular disease were reviewed. The trials examined the cardiovascular safety outcomes of the following agents: alogliptin, saxagliptin, and sitagliptin (dipeptidyl peptidase-4 [DPP-4] inhibitors); liraglutide, lixisenatide, and semaglutide (glucagon-like peptide-1 agonists); and empagliflozin (a sodium glucose cotransport-2 inhibitor). The DPP-4 inhibitor and lixisenatide trials showed a neutral effect on cardiovascular events (composite of cardiovascular death, myocardial infarction, or stroke, with or without unstable angina). Empagliflozin showed a significant reduction in cardiovascular events, cardiovascular death, all-cause death, and hospitalization due to heart failure (HF); liraglutide reduced cardiovascular events, cardiovascular death, and all-cause death, and semaglutide reduced cardiovascular events and nonfatal stroke. Most studies showed a neutral effect of the drug on hospitalization for HF; however, saxagliptin and alogliptin (in the subgroups of patients without a history of HF) showed a significant increase while empagliflozin showed a significant reduction in hospitalizations for HF. The data for empagliflozin, liraglutide, and semaglutide are compelling; however, further studies are necessary to confirm observed benefits and better characterize long-term safety and their use as a strategy to reduce cardiovascular events. CONCLUSION A review of cardiovascular safety outcomes for new antidiabetic agents found that saxagliptin and alogliptin were associated with an increase in hospitalization for HF. The data for empagliflozin, liraglutide, and semaglutide showed a reduction in cardiovascular events and death or a neutral effect on cardiovascular endpoints.
Collapse
Affiliation(s)
- Marlys H LeBras
- RxFiles Academic Detailing Program, Saskatoon Health Region, Saskatoon, Saskatchewan, Canada
| | - Arden R Barry
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada .,Chilliwack General Hospital, Lower Mainland Pharmacy Services, Chilliwack, British Columbia, Canada.
| | - Sheri L Koshman
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
41
|
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.
Collapse
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
| |
Collapse
|
42
|
Cardiovascular Safety of Dipeptidyl-Peptidase IV Inhibitors: A Meta-Analysis of Placebo-Controlled Randomized Trials. Am J Cardiovasc Drugs 2017; 17:143-155. [PMID: 27873238 DOI: 10.1007/s40256-016-0208-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Large randomized trials have shown conflicting evidence regarding the cardiovascular safety of dipeptidyl-peptidase 4 (DPP-4) inhibitors. Systematic reviews have been limited by incomplete data and inclusion of observational studies. This study aimed to systematically evaluate the cardiovascular safety of DPP-4 inhibitors in patients with type 2 diabetes. METHODS Electronic databases were searched for randomized trials that compared DPP-4 inhibitors versus placebo and reported cardiovascular outcomes. The main outcome assessed in this analysis was heart failure. Other outcomes included all-cause mortality, cardiovascular mortality, myocardial infarction, and ischemic stroke. Summary odds ratios (ORs) were primarily constructed using Peto's model. RESULTS A total of 90 trials with 66,730 patients were included. Compared with placebo, DPP-4 inhibitors were associated with a non-significant increased risk of heart failure [OR 1.11, 95% confidence interval (CI) 0.99-1.25, P = 0.07] at a mean of 108 weeks. The risk of all-cause mortality (OR 1.03, 95% CI 0.94-1.12, P = 0.53), cardiovascular mortality (OR 1.02, 95% CI 0.92-1.14, P = 0.72), myocardial infarction (OR 0.98, 95% CI 0.88-1.09, P = 0.69), and ischemic stroke (OR 0.99, 95% CI 0.85-1.15, P = 0.92) was similar between both groups. CONCLUSION In patients with type 2 diabetes, the safety profile of DPP-4 inhibitors is similar to placebo. As a class, there is only weak evidence for an increased risk of heart failure.
Collapse
|
43
|
Lourenço P, Silva S, Cunha F, Pereira J, Ribeiro A, Silva N, Guimarães JT, Araújo JP, Bettencourt P. Dipeptidyl peptidase-IV in chronic heart failure with reduced ejection fraction. Int J Cardiol 2017; 241:249-254. [PMID: 28318663 DOI: 10.1016/j.ijcard.2017.03.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/14/2017] [Accepted: 03/09/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND An association between dipeptidyl peptidase-IV (DPP-IV) inhibitors with worse prognosis in HF has been suggested. We aimed to assess the serum DPP-IV levels in chronic stable HF patients and determine their association with prognosis. METHODS AND RESULTS Chronic stable HF patients with optimized prognostic-modifying therapy were prospectively recruited. EXCLUSION CRITERIA 1) ejection fraction>50%, 2) hospitalizations or therapeutic adjustments in the previous 2months; 3) patients on renal replacement therapy, and 4) use of DPP-IV inhibitors. A fasting venous blood sample was collected and DPP-IV was measured. Patients were followed-up for 3years and the endpoint studied was all-cause death. Patients' characteristics were compared according to DPP-IV quartiles. A Cox regression analysis was performed and multivariate models were built. The 3rd DPP-IV quartile was the reference category. We studied 264 patients. Mean age: 69 (±13)years, 70.5% were male and 33.7% diabetic. Median (IQR) serum DPP-IV levels were 455.6 (350.0-625.5)ng/mL. DPP-IV had an inverse relationship with age. Patients in 3rd DPP-IV quartile were in lower NYHA classes and had the lowest 3years all-cause mortality. Patients in the 1st DPP-IV quartile had a multivariate adjusted HR of 3-year mortality of 2.62 (95%CI: 1.15-5.95) when compared with reference category and the HR for the 4th quartile was of 3.79 (95%CI: 1.68-8.54). CONCLUSIONS There is a U-shaped association of serum DPP-IV with mortality in chronic systolic HF patients. Patients in the 3rd DPP-IV quartile have the best multivariate adjusted 3-year survival. DPP-IV inhibition might be harmful in patients with low DPP-IV.
Collapse
Affiliation(s)
| | - Sérgio Silva
- Serviço de Medicina Interna,Centro Hospitalar São João, Portugal
| | - Filipe Cunha
- Serviço de Endocrinologia, Centro Hospitalar São João, Portugal
| | - Joana Pereira
- Serviço de Medicina Interna,Centro Hospitalar São João, Portugal
| | - Ana Ribeiro
- Serviço de Medicina Interna,Centro Hospitalar São João, Portugal
| | - Nuno Silva
- Serviço de Patologia Clínica, Centro Hospitalar São João, Portugal
| | - João Tiago Guimarães
- Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal; Serviço de Patologia Clínica, Centro Hospitalar São João, Portugal
| | - José Paulo Araújo
- Serviço de Medicina Interna,Centro Hospitalar São João, Portugal; Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal
| | - Paulo Bettencourt
- Serviço de Medicina Interna,Centro Hospitalar São João, Portugal; Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal
| |
Collapse
|
44
|
Crowley MJ, Diamantidis CJ, McDuffie JR, Cameron CB, Stanifer JW, Mock CK, Wang X, Tang S, Nagi A, Kosinski AS, Williams JW. Clinical Outcomes of Metformin Use in Populations With Chronic Kidney Disease, Congestive Heart Failure, or Chronic Liver Disease: A Systematic Review. Ann Intern Med 2017; 166:191-200. [PMID: 28055049 PMCID: PMC5293600 DOI: 10.7326/m16-1901] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Recent changes to the U.S. Food and Drug Administration boxed warning for metformin will increase its use in persons with historical contraindications or precautions. Prescribers must understand the clinical outcomes of metformin use in these populations. PURPOSE To synthesize data addressing outcomes of metformin use in populations with type 2 diabetes and moderate to severe chronic kidney disease (CKD), congestive heart failure (CHF), or chronic liver disease (CLD) with hepatic impairment. DATA SOURCES MEDLINE (via PubMed) from January 1994 to September 2016, and Cochrane Library, EMBASE, and International Pharmaceutical Abstracts from January 1994 to November 2015. STUDY SELECTION English-language studies that: 1) examined adults with type 2 diabetes and CKD (with estimated glomerular filtration rate less than 60 mL/min/1.73 m2), CHF, or CLD with hepatic impairment; 2) compared diabetes regimens that included metformin with those that did not; and 3) reported all-cause mortality, major adverse cardiovascular events, and other outcomes of interest. DATA EXTRACTION 2 reviewers abstracted data and independently rated study quality and strength of evidence. DATA SYNTHESIS On the basis of quantitative and qualitative syntheses involving 17 observational studies, metformin use is associated with reduced all-cause mortality in patients with CKD, CHF, or CLD with hepatic impairment, and with fewer heart failure readmissions in patients with CKD or CHF. LIMITATIONS Strength of evidence was low, and data on multiple outcomes of interest were sparse. Available studies were observational and varied in follow-up duration. CONCLUSION Metformin use in patients with moderate CKD, CHF, or CLD with hepatic impairment is associated with improvements in key clinical outcomes. Our findings support the recent changes in metformin labeling. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs. (PROSPERO: CRD42016027708).
Collapse
Affiliation(s)
- Matthew J. Crowley
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of Endocrinology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Clarissa J. Diamantidis
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jennifer R. McDuffie
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - C. Blake Cameron
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - John W. Stanifer
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Clare K. Mock
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Xianwei Wang
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
| | - Shuang Tang
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
| | - Avishek Nagi
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
| | - Andrzej S. Kosinski
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - John W. Williams
- Evidence-based Synthesis Program, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| |
Collapse
|
45
|
Singh AK, Singh R. SAVOR-TIMI to SUSTAIN-6: a critical comparison of cardiovascular outcome trials of antidiabetic drugs. Expert Rev Clin Pharmacol 2017; 10:429-442. [PMID: 28121469 DOI: 10.1080/17512433.2017.1287562] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Since the inception of mandatory cardiovascular (CV) safety outcome trial (CVOT) promulgated by US FDA in 2008, seven trials have so far been published with three different classes of antidiabetic drugs in type 2 diabetes mellitus (T2DM). This mini-review aims to critically analyse these CVOTs in terms of different outcomes achieved. Areas covered: An electronic search pertaining to the subject was conducted till September 2016. The three CVOT conducted with saxagliptin, alogliptin and sitagliptin respectively, found them to be CV-neutral. However, both saxagliptin and alogliptin showed an increase in hospitalization due to heart failure (hHF), while sitagliptin had no such signal. The trial conducted with empagliflozin (EMPA-REG) found it to be superior in reducing major adverse cardiac events (MACE). The CVOT conducted with lixisenatide (ELIXA) was CV-neutral, but both liraglutide (LEADER) and semaglutide (SUSTAIN-6) demonstrated superiority in reducing MACE. Expert commentary: While EMPA-REG had robust reduction in the CV-death, all-cause death and hHF, there was a discordant non-significant increase in silent myocardial infarction (MI) (assessed in approximately 50% of patients) and non-fatal stroke. LEADER had concordant reduction in all CV endpoints. SUSTAIN-6 had most robust reduction in 3P-MACE, although no reduction in the CV-death, all-cause death and hHF were observed.
Collapse
Affiliation(s)
- Awadhesh Kumar Singh
- a Department of Endocrinology , G.D Hospital & Diabetes Institute , Kolkata , West Bengal , India
| | - Ritu Singh
- b Department of Gynecology , G.D Hospital & Diabetes Institute , Kolkata , West Bengal , India
| |
Collapse
|
46
|
|
47
|
Abstract
PURPOSE OF REVIEW It is well known that patients with heart failure also suffer from a large number of comorbid conditions, which confound their heart failure management and adversely affect the prognosis. The purpose of this review is to evaluate the latest developments of these conditions. RECENT FINDINGS Chronic lung disease commonly coexists with heart failure. It is more prevalent and worsens prognosis more in patients with preserved (heart failure with preserved ejection fraction) than with reduced ejection fraction (heart failure with reduced ejection fraction). Patients with diabetes have increased risk of incident heart failure, and as a comorbid condition it adversely affects prognosis. The relative impact on mortality and heart failure hospitalization remains controversial. Renal dysfunction is also common in patients with heart failure, with similar prevalence among those with preserved ejection fraction and those with reduced ejection fraction. The prognosis seems mainly related to long-term changes in kidney function, rather than to short-term changes in serum creatinine. Anemia and iron deficiency have a similar profile in terms of prevalence and impact on prognosis. Recent data suggest a benefit of intravenous iron infusion in patients who are iron deficient. SUMMARY As patients with comorbid conditions are frequently excluded from clinical trials, future clinical trials should recruit these patients and include endpoints that will be reflective of these conditions.
Collapse
|
48
|
Xiao X, Cui X, Zhang J, Han Z, Xiao Y, Chen N, Li B, Cheng M, Gao H, Tang K. Effects of sitagliptin as initial therapy in newly diagnosed elderly type 2 diabetics: A randomized controlled study. Exp Ther Med 2016; 12:3002-3008. [PMID: 27882107 PMCID: PMC5103735 DOI: 10.3892/etm.2016.3729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 09/06/2016] [Indexed: 12/23/2022] Open
Abstract
The objective of this study was to investigate the characteristics of blood glycemic excursion, incretins and pancreatic hormone secretion in elderly people with newly diagnosed type 2 diabetes mellitus (T2DM) and to study the effects of sitagliptin on glycemic excursion in these subjects. A total of 129 newly diagnosed T2DM patients were enrolled in the study from March 2012 to August 2013. Clinical data, serum incretin, pancreatic hormone and continuous glucose monitoring data were collected. Among these subjects, elderly patients (NEDM) randomly received metformin combined with sitagliptin phosphate or glimepiride for 24 weeks. The blood glucose, glycosylated hemoglobin A1c (GHbA1c), serum incretins and pancreatic hormone levels were determined. During the oral glucose tolerance test (OGTT), 30 min insulin and C-peptide levels, 120 min insulin levels and ratio of the increases of insulin and blood glucose levels after 30 min of sugar loading (∆Ins30/∆Glu30) were significantly lower in elderly patients than in middle-aged patients (P<0.05). In addition, the glucagon elevation at 30 min was higher and the glucagon-like peptide-1 (GLP-1) at 30 min was lower in the elderly patients (P<0.05). Glucose excursion indices, including the standard deviation of the average blood glucose, intraday mean average glucose excursions (MAGE), and mean of daily differences (MODD), were significantly higher in the elderly patients (P<0.05). During the OGTT, insulin, C-peptide and ∆Ins30/∆Glu30 results at 30 min and GLP-1 levels at 120 min in NEDM subjects were significantly increased (P<0.05) and glucagon levels at 30 min was significantly lower after sitagliptin treatment (P<0.05) compared with glimepiride. Moreover, MAGE and MODD were significantly lower in the sitagliptin group after treatment compared to those in the glimepiride group (P<0.05). No severe hypoglycemia or cardiovascular diseases were observed. Strong blood glucose excursions occur in elderly patients with newly diagnosed T2DM. Sitagliptin phosphate combined with metformin effectively and safely improves glycemic excursion and carbohydrate metabolism in NEDM patients by promoting the first phase of insulin and incretin secretion and inhibiting glucagon secretion of.
Collapse
Affiliation(s)
- Xiaoyan Xiao
- Department of Nephrology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xiaopei Cui
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Jianbo Zhang
- Department of Emergency, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Zhenxia Han
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Yu Xiao
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Nan Chen
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Baoying Li
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Mei Cheng
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Haiqing Gao
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Kuanxiao Tang
- Department of Geriatrics, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| |
Collapse
|
49
|
Ou SM, Chen HT, Kuo SC, Chen TJ, Shih CJ, Chen YT. Dipeptidyl peptidase-4 inhibitors and cardiovascular risks in patients with pre-existing heart failure. Heart 2016; 103:414-420. [PMID: 27647170 DOI: 10.1136/heartjnl-2016-309687] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 08/08/2016] [Accepted: 08/15/2016] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Although recent clinical trials raised concerns about the risk for heart failure (HF) in dipeptidyl peptidase-4 (DPP-4) inhibitor use, data on the cardiovascular risks in the patients with pre-existing HF are still lacking. METHODS We used Taiwan's National Health Insurance Research Database to identify 196 986 patients diagnosed with type 2 diabetes mellitus (T2DM) who had previous history of HF between 2009 and 2013. This population included 30 204 DPP-4 inhibitor users and 166 782 propensity score-matched DPP-4 inhibitor non-users. The outcomes of interest were all-cause mortality, combination of myocardial infarction (MI) and ischaemic stroke, and hospitalisation for HF. RESULTS The incidence in DPP-4 users compared with non-users was 67.02 vs 102.85 per 1000 person-years for all-cause mortality, 37.89 vs 47.54 per 1000 person-years for the combination of MI and ischaemic stroke, 12.70 vs 16.18 per 1000 person-years for MI and 26.37 vs 32.46 per 1000 person-years for ischaemic stroke. The risk of all-cause mortality was lower in DPP-4 inhibitor users (HR 0.67, 95% CI 0.64 to 0.70), combination of MI and stroke (HR 0.81, 95% CI 0.76 to 0.87), MI (HR 0.80, 95% CI 0.71 to 0.89) and ischaemic stroke (HR 0.83, 95% CI 0.76 to 0.89) than in non-users. Notably, the risk of hospitalisation for HF did not differ significantly between groups. The results were similar after accounting for death as a competing risk. CONCLUSIONS In this nationwide T2DM cohort, the risks of mortality and the combination of MI and ischaemic stroke were lower for patients receiving DPP-4 inhibitors than for those who did not receive such treatment. DPP-4 inhibitor use was not associated with a higher risk of hospitalisation for HF even in patients with pre-existing HF.
Collapse
Affiliation(s)
- Shuo-Ming Ou
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hung-Ta Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Endocrinology and Metabolism, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan
| | - Shu-Chen Kuo
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan.,National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Jen Shih
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan
| | - Yung-Tai Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan
| |
Collapse
|
50
|
Ceriello A, Genovese S, Mannucci E, Gronda E. Glucagon and heart in type 2 diabetes: new perspectives. Cardiovasc Diabetol 2016; 15:123. [PMID: 27568179 PMCID: PMC5002329 DOI: 10.1186/s12933-016-0440-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 08/13/2016] [Indexed: 02/06/2023] Open
Abstract
Increased levels of glucagon in type 2 diabetes are well known and, until now, have been considered deleterious. However, glucagon has an important role in the maintenance of both heart and kidney function. Moreover, in the past, glucagon has been therapeutically used for heart failure treatment. The new antidiabetic drugs, dipeptidyl peptidase-4 inhibitors and sodium-glucose co-transporter-2 inhibitors, are able to decrease and to increase glucagon levels, respectively, while contrasting data have been reported regarding the glucagon like peptide 1 receptors agonists. The cardiovascular outcome trials, requested by the FDA, raised some concerns about the possibility that the dipeptidyl peptidase-4 inhibitors can precipitate the heart failure, while, at least for empagliflozin, a positive effect has been shown in decreasing both cardiovascular death and heart failure. The recent LEADER Trial, showed a significant reduction of cardiovascular death with liraglutide, but a neutral effect on heart failure. A possible explanation of the results with the DPPIV inhibitors and empagliflozin might be related to their divergent effect on glucagon levels. Due to unclear effects of glucagon like peptide 1 receptor agonists on glucagon, the possible role of this hormone in the Leader trial remains unclear.
Collapse
Affiliation(s)
- Antonio Ceriello
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomedica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), C/Rosselló, 149-153, 08036 Barcelona, Spain
- Department of Cardiovascular and Metabolic Diseases, IRCCS Multimedica, Sesto San Giovanni, MI Italy
| | - Stefano Genovese
- Department of Cardiovascular and Metabolic Diseases, IRCCS Multimedica, Sesto San Giovanni, MI Italy
| | - Edoardo Mannucci
- Diabetology, Careggi Hospital, University of Florence, Florence, Italy
| | - Edoardo Gronda
- Department of Cardiovascular and Metabolic Diseases, IRCCS Multimedica, Sesto San Giovanni, MI Italy
| |
Collapse
|