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Mondal S, Pramanik S, Khare VR, Fernandez CJ, Pappachan JM. Sodium glucose cotransporter-2 inhibitors and heart disease: Current perspectives. World J Cardiol 2024; 16:240-259. [PMID: 38817648 PMCID: PMC11135334 DOI: 10.4330/wjc.v16.i5.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 04/08/2024] [Accepted: 04/28/2024] [Indexed: 05/23/2024] Open
Abstract
Sodium glucose cotransporter-2 inhibitors (SGLT-2i) are antidiabetic medications with remarkable cardiovascular (CV) benefits proven by multiple randomised controlled trials and real-world data. These drugs are also useful in the prevention of CV disease (CVD) in patients with diabetes mellitus (DM). Although DM as such is a huge risk factor for CVD, the CV benefits of SGLT-2i are not just because of antidiabetic effects. These molecules have proven beneficial roles in prevention and management of nondiabetic CVD and renal disease as well. There are various molecular mechanisms for the organ protective effects of SGLT-2i which are still being elucidated. Proper understanding of the role of SGLT-2i in prevention and management of CVD is important not only for the cardiologists but also for other specialists caring for various illnesses which can directly or indirectly impact care of heart diseases. This clinical review compiles the current evidence on the rational use of SGLT-2i in clinical practice.
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Affiliation(s)
- Sunetra Mondal
- Department of Endocrinology, NRS Medical College, Kolkata 700020, West Bengal, India
| | - Subhodip Pramanik
- Department of Endocrinology, Neotia Getwel Multispecialty Hospitals, Siliguri 734010, West Bengal, India
| | - Vibhu Ranjan Khare
- Department of Endocrinology, NRS Medical College, Kolkata 700020, West Bengal, India
| | - Cornelius James Fernandez
- Department of Endocrinology and Metabolism, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston PE21 9QS, United Kingdom
| | - Joseph M Pappachan
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
- Faculty of Science, Manchester Metropolitan University, Manchester M15 6BH, United Kingdom
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PL, United Kingdom.
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2
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Zhang Q, Hu S, Jin Z, Wang S, Zhang B, Zhao L. Mechanism of traditional Chinese medicine in elderly diabetes mellitus and a systematic review of its clinical application. Front Pharmacol 2024; 15:1339148. [PMID: 38510656 PMCID: PMC10953506 DOI: 10.3389/fphar.2024.1339148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/31/2024] [Indexed: 03/22/2024] Open
Abstract
Objective: Affected by aging, the elderly diabetes patients have many pathological characteristics different from the young people, including more complications, vascular aging, cognitive impairment, osteoporosis, and sarcopenia. This article will explore their pathogenesis and the mechanism of Traditional Chinese medicine (TCM) intervention, and use the method of systematic review to evaluate the clinical application of TCM in elderly diabetes. Method: Searching for randomized controlled trials (RCTs) published from January 2000 to November 2023 in the following databases: Web of Science, Pubmed, Embase, Cochrane Library, Sinomed, China National Knowledge Internet, Wanfang and VIP. They were evaluated by three subgroups of Traditional Chinese Prescription, Traditional Chinese patent medicines and Traditional Chinese medicine extracts for their common prescriptions, drugs, adverse reactions and the quality of them. Results and Conclusion: TCM has the advantages of multi-target and synergistic treatment in the treatment of elderly diabetes. However, current clinical researches have shortcomings including the inclusion of age criteria and diagnosis of subjects are unclear, imprecise research design, non-standard intervention measures, and its safety needs further exploration. In the future, the diagnosis of elderly people with diabetes needs to be further clarified. Traditional Chinese patent medicines included in the pharmacopoeia can be used to conduct more rigorous RCTs, and then gradually standardize the traditional Chinese medicine prescriptions and traditional Chinese medicine extracts, providing higher level evidence for the treatment of elderly diabetes with traditional Chinese medicine.
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Affiliation(s)
- Qiqi Zhang
- Institute of Metabolic Diseases, Guang’anmen Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China
| | - Shiwan Hu
- Institute of Metabolic Diseases, Guang’anmen Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Zishan Jin
- Institute of Metabolic Diseases, Guang’anmen Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Sicheng Wang
- Institute of Metabolic Diseases, Guang’anmen Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China
| | - Boxun Zhang
- Department of Endocrinology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Linhua Zhao
- Institute of Metabolic Diseases, Guang’anmen Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China
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Gupta R, Maitz T, Egeler D, Mehta A, Nyaeme M, Hajra A, Goel A, Sreenivasan J, Patel N, Aronow WS. SGLT2 inhibitors in hypertension: Role beyond diabetes and heart failure. Trends Cardiovasc Med 2023; 33:479-486. [PMID: 35597430 DOI: 10.1016/j.tcm.2022.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/05/2022] [Accepted: 05/14/2022] [Indexed: 12/15/2022]
Abstract
Type 2 Diabetes Mellitus (T2DM) is a pandemic that affects millions of patients worldwide. Diabetes affects multiple organ systems leading to comorbidities including hypertension. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) recently have been approved for the treatment of T2DM and heart failure with reduced and preserved ejection fraction. Retrospective analyses of clinical trials have noted SGLT2 inhibitors to have a promising effect on blood pressure. Moreover, the observed blood pressure reduction is not just an acute effect of treatment initiation but has been shown to have a long-term impact on both systolic and diastolic blood pressure. The mechanism of action leading to the blood pressure reduction is still unclear; however, proposed mechanisms are related to the natriuretic effect, modification of the renin-angiotensin-aldosterone system, and/or the reduction in the sympathetic nervous system, SGLT2i should be considered as second-line medication in those patients with diabetes or heart disease and concomitant hypertension. This article reviews the pharmacology, side effect profile, and clinical trials surrounding the use of SGLT2i for the treatment of hypertension.
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Affiliation(s)
- Rahul Gupta
- Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA.
| | - Theresa Maitz
- Department of Medicine, Lehigh Valley Health Network, Allentown, PA, USA
| | - David Egeler
- Department of Medicine, Lehigh Valley Health Network, Allentown, PA, USA
| | - Anila Mehta
- Department of Medicine, Carle Foundation Hospital, Urbana, IL, USA
| | - Mark Nyaeme
- Department of Medicine, Carle Foundation Hospital, Urbana, IL, USA
| | - Adrija Hajra
- Department of Medicine, Jacobi Medical Center, Bronx, NY, USA
| | - Akshay Goel
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Jayakumar Sreenivasan
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Neel Patel
- Department of Cardiology, Kansas University Medical Center, Kansas City, KS, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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Sodium Glucose Cotransporter 2 Inhibitors, Amputation Risk, and Fracture Risk. Heart Fail Clin 2022; 18:645-654. [DOI: 10.1016/j.hfc.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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5
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Hofbauer LC, Busse B, Eastell R, Ferrari S, Frost M, Müller R, Burden AM, Rivadeneira F, Napoli N, Rauner M. Bone fragility in diabetes: novel concepts and clinical implications. Lancet Diabetes Endocrinol 2022; 10:207-220. [PMID: 35101185 DOI: 10.1016/s2213-8587(21)00347-8] [Citation(s) in RCA: 117] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/09/2021] [Accepted: 12/09/2021] [Indexed: 12/12/2022]
Abstract
Increased fracture risk represents an emerging and severe complication of diabetes. The resulting prolonged immobility and hospitalisations can lead to substantial morbidity and mortality. In type 1 diabetes, bone mass and bone strength are reduced, resulting in up to a five-times greater risk of fractures throughout life. In type 2 diabetes, fracture risk is increased despite a normal bone mass. Conventional dual-energy x-ray absorptiometry might underestimate fracture risk, but can be improved by applying specific adjustments. Bone fragility in diabetes can result from cellular abnormalities, matrix interactions, immune and vascular changes, and musculoskeletal maladaptation to chronic hyperglycaemia. This Review summarises how the bone microenvironment responds to type 1 and type 2 diabetes, and the mechanisms underlying fragility fractures. We describe the value of novel imaging technologies and the clinical utility of biomarkers, and discuss current and future therapeutic approaches that protect bone health in people with diabetes.
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Affiliation(s)
- Lorenz C Hofbauer
- Division of Endocrinology, Diabetes and Bone Diseases, Department of Medicine III, and Center for Healthy Aging, University Medical Center, Technische Universität Dresden, Dresden, Germany.
| | - Björn Busse
- Department of Osteology and Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Richard Eastell
- Department of Oncology and Metabolism, Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, UK
| | - Serge Ferrari
- Service and Laboratory of Bone Diseases, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
| | - Morten Frost
- Molecular Endocrinology Laboratory and Steno Diabetes Centre Odense, Odense University Hospital, Odense, Denmark
| | - Ralph Müller
- Institute of Biomechanics, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Andrea M Burden
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | | | - Nicola Napoli
- RU of Endocrinology and Diabetes, Campus Bio-Medico University of Rome and Fondazione Policlinico Campus Bio-Medico, Rome, Italy; Division of Bone and Mineral Diseases, Washington University in St Louis, St Louis, MO, USA
| | - Martina Rauner
- Division of Endocrinology, Diabetes and Bone Diseases, Department of Medicine III, and Center for Healthy Aging, University Medical Center, Technische Universität Dresden, Dresden, Germany
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Dong B, Lv R, Wang J, Che L, Wang Z, Huai Z, Wang Y, Xu L. The Extraglycemic Effect of SGLT-2is on Mineral and Bone Metabolism and Bone Fracture. Front Endocrinol (Lausanne) 2022; 13:918350. [PMID: 35872985 PMCID: PMC9302585 DOI: 10.3389/fendo.2022.918350] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/30/2022] [Indexed: 12/02/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a risk factor for osteoporosis. The effects of T2DM and anti-diabetic agents on bone and mineral metabolism have been observed. Sodium-glucose co-transporter 2 inhibitors (SGLT-2is) promote urinary glucose excretion, reduce blood glucose level, and improve the cardiovascular and diabetic nephropathy outcomes. In this review, we focused on the extraglycemic effect and physiological regulation of SGLT-2is on bone and mineral metabolism. SGLT-2is affect the bone turnover, microarchitecture, and bone strength indirectly. Clinical evidence of a meta-analysis showed that SGLT-2is might not increase the risk of bone fracture. The effect of SGLT-2is on bone fracture is controversial, and further investigation from a real-world study is needed. Based on its significant benefit on cardiovascular and chronic kidney disease (CKD) outcomes, SGLT-2is are an outstanding choice. Bone mineral density (BMD) and fracture risk evaluation should be considered for patients with a high risk of bone fracture.
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Affiliation(s)
- Bingzi Dong
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ruolin Lv
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jun Wang
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lin Che
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhongchao Wang
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhouyang Huai
- Department of Geriatric Medicine, Yantai Yuhuangding Hospital Affiliated Hospital of Qingdao University, Yantai, China
| | - Yangang Wang
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Lili Xu, ; Yangang Wang,
| | - Lili Xu
- Department of Endocrinology and Metabolism, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Lili Xu, ; Yangang Wang,
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Masajtis-Zagajewska A, Hołub T, Pęczek K, Makówka A, Nowicki M. Different Effects of Empagliflozin on Markers of Mineral-Bone Metabolism in Diabetic and Non-Diabetic Patients with Stage 3 Chronic Kidney Disease. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:1352. [PMID: 34946298 PMCID: PMC8705759 DOI: 10.3390/medicina57121352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/02/2021] [Accepted: 12/08/2021] [Indexed: 02/07/2023]
Abstract
Background and objectives: Treatment with sodium-glucose co-transporter 2 (SGLT2) inhibitors decrease tubular reabsorption of phosphate, which may explain the reduction of bone mineral density and an excess of bone fractures observed in some studies with this class of drugs. Since an increased risk of bone fractures may also be a result of diabetes itself, our study aimed to compare the effect of empagliflozin on the markers of mineral-bone metabolism between diabetic (DKD) and non-diabetic (ND-CKD) patients with stage 3 chronic kidney disease (CKD). Materials and Methods: Forty-two patients with stage 3 CKD and A2 albuminuria, including 18 with DKD and 24 ND-CKD, were investigated. All subjects received 10 mg empagliflozin for 7 days. Serum calcium, phosphate, parathormone (PTH), calcitriol, bone alkaline phosphatase (BAP), FGF-23 and urine calcium, phosphate, albumin and the renal tubular maximum reabsorption rate of phosphate to the glomerular filtration rate (TmP-GFR) were measured before and after empagliflozin administration. Differences in biomarkers response to empagliflozin between DKD and ND-CKD were the main measures of outcome. Results: There was a significant increase of PTH, FGF-23 and phosphate in DKD but not in ND-CKD whereas BAP and TmP/GFR did not change in either group. The reduction of albuminuria was only significant in ND-CKD. Conclusions: The effect of SGLT2 inhibitor on serum mineral and bone markers and on albuminuria in patients with CKD may be differently modified by the presence of diabetes mellitus.
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Affiliation(s)
| | | | | | | | - Michał Nowicki
- Department of Nephrology, Hypertension and Kidney Transplantation, Medical University of Lodz, Central University Hospital, 92-213 Lodz, Poland; (A.M.-Z.); (T.H.); (K.P.); (A.M.)
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Scheen AJ. Sodium-glucose cotransporter type 2 inhibitors for the treatment of type 2 diabetes mellitus. Nat Rev Endocrinol 2020; 16:556-577. [PMID: 32855502 DOI: 10.1038/s41574-020-0392-2] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Abstract
The management of type 2 diabetes mellitus (T2DM) is becoming increasingly complex. Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are the newest antidiabetic agents for T2DM. By targeting the kidney, they have a unique mechanism of action, which results in enhanced glucosuria, osmotic diuresis and natriuresis, thereby improving glucose control with a limited risk of hypoglycaemia and exerting additional positive effects such as weight loss and the lowering of blood pressure. Several outcome studies with canagliflozin, dapagliflozin or empagliflozin reported a statistically significant reduction in major cardiovascular events, hospitalization for heart failure and progression to advanced renal disease in patients with T2DM who have established atherosclerotic cardiovascular disease, several cardiovascular risk factors, albuminuric mild to moderate chronic kidney disease or heart failure. Current guidelines proposed a new paradigm in the management of T2DM, with a preferential place for SGLT2is, after metformin, in patients with atherosclerotic cardiovascular disease, heart failure and progressive kidney disease. Ongoing trials might extend the therapeutic potential of SGLT2is in patients with, but also without, T2DM. This Review provides an update of the current knowledge on SGLT2is, moving from their use as glucose-lowering medications to their new positioning as cardiovascular and renal protective agents.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
- Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
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Chrysant SG, Chrysant GS. New and emerging cardiovascular and antihypertensive drugs. Expert Opin Drug Saf 2020; 19:1315-1327. [DOI: 10.1080/14740338.2020.1810232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Steven G. Chrysant
- Department of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - George S. Chrysant
- Department of Cardiology, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
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Effects of sodium glucose cotransporter 2 inhibitors on mineral metabolism in type 2 diabetes mellitus. Curr Opin Nephrol Hypertens 2020; 28:321-327. [PMID: 30958403 PMCID: PMC6587226 DOI: 10.1097/mnh.0000000000000505] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose of review Sodium glucose cotransporter 2 (SGLT2) inhibitors are relatively novel antidiabetic drugs that improve glycemic control and reduce cardiovascular outcomes as well as renal function decline. SGLT2 inhibitors act by inhibiting glucose reabsorption in the proximal tubule of the kidney. Emerging data suggest that these drugs may also influence bone and mineral metabolism. This review summarizes clinical trial data on bone and mineral outcomes, and discusses potential underlying mechanisms. Recent findings Three large randomized controlled trials documented cardiovascular and renal protective effects of SGLT2 inhibitors. Recent studies indicate that SGLT2 inhibitors influence renal phosphate reabsorption and calciuria. Although the CANVAS trial suggested an increased fracture risk associated with canagliflozin compared with placebo, the vast majority of trials and meta-analyses did not demonstrate an increased fracture risk associated with SGLT2 inhibitor use. Summary SGLT2 inhibitors have shown clinically relevant cardiovascular and renal protective effects. The long-term implications for bone health, in particular in the context of chronic kidney disease, are still incompletely understood and warrant further investigation.
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Singh M, Sharma R, Kumar A. Safety of SGLT2 Inhibitors in Patients with Diabetes Mellitus. Curr Drug Saf 2020; 14:87-93. [PMID: 30727912 DOI: 10.2174/1574886314666190206164647] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Recently, Food and Drug Administration (FDA) has approved sodium/ glucose co-transporter 2 (SGLT2) inhibitors for the treatment of diabetes mellitus. However, regarding adverse drug reactions (ADRs) of SGLT2 inhibitors in large group of population, very less information is available. Thus, we have tried to find out the risk profile of SGLT2 inhibitors. MATERIALS AND METHODS A total of 1,042 studies have been published from Nov. 2012-Nov. 2017 regarding SGLT2 inhibitors. After inclusion and exclusion criteria, 27 studies have been selected for the analysis of risk. RESULTS AND DISCUSSION The emerging evidence indicates various adverse drug reactions such as foot and toe amputation, cancer, diabetic ketoacidosis, bone fracture risk and urinary as well as mycotic genital infection. The causality assessment has shown a correlation between SGLT2 inhibitors and diabetic ketoacidosis and urinary tract infection. CONCLUSION In conclusion, Marketing Authorization Holder (MAH) and Regulatory Authorities (RA) should monitor various adverse drug reactions such as diabetic ketoacidosis and urinary tract infection with the use of SGLT2 inhibitor.
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Affiliation(s)
- Mahakpreet Singh
- Department of Pharmacy Practice, Indo-Soviet Friendship Pharmacy College (ISFCP), Moga, Punjab, India
| | - Ruchika Sharma
- Department of Biotechnology, Indo-Soviet Friendship Institute of Professional Studies (ISFIPS), Moga, Punjab, India
| | - Anoop Kumar
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPERRaebareli), Lucknow, UP, India
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McGill JB, Subramanian S. Safety of Sodium-Glucose Co-Transporter 2 Inhibitors. Am J Cardiol 2019; 124 Suppl 1:S45-S52. [PMID: 31741440 DOI: 10.1016/j.amjcard.2019.10.029] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/06/2019] [Indexed: 12/17/2022]
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors have a well-defined safety profile based on data obtained from numerous clinical trials, including cardiovascular outcomes trials (CVOTs) and postmarketing pharmacovigilance reporting. Adverse events including risk of genital mycotic infection and volume depletion-related events are consistent with the mechanism of action of this drug class. However, several emergent (albeit infrequent) serious safety issues have also been reported. In their respective CVOTs, the proportion of patients with reported diabetic ketoacidosis was similar in empagliflozin or canagliflozin compared with their placebo groups, but it was higher for dapagliflozin. Canagliflozin may be associated with an increased risk of bone fracture and lower limb amputation; however, data are inconclusive. There is no evidence linking SGLT2 inhibitors with an increased risk of cancer, but these agents, particularly dapagliflozin, should be used with caution in patients with hematuria or a history of bladder cancer. Postmarketing reports of acute kidney injury have occurred in patients receiving SGLT2 inhibitors, and cases identified in recent CVOTs occurred with similar frequency in SGLT2 inhibitor and placebo groups. Common adverse events associated with SGLT2 inhibitors (such as genital infections or volume depletion) are generally mild and manageable by patients or by primary care physicians, and the risk of rare events (such as ketoacidosis) can be minimized by appropriate patient selection and early recognition of symptoms. When selecting treatment, it is important that clinicians weigh the known risks of SGLT2 inhibitors against their proven benefits, including the reduction of adverse cardiovascular and renal outcomes.
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Affiliation(s)
- Janet B McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, Mo.
| | - Savitha Subramanian
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle
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Dekkers CCJ, Wheeler DC, Sjöström CD, Stefansson BV, Cain V, Heerspink HJL. Effects of the sodium-glucose co-transporter 2 inhibitor dapagliflozin in patients with type 2 diabetes and Stages 3b-4 chronic kidney disease. Nephrol Dial Transplant 2019; 33:2005-2011. [PMID: 29370424 PMCID: PMC6212718 DOI: 10.1093/ndt/gfx350] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/01/2017] [Indexed: 01/10/2023] Open
Abstract
Background The sodium–glucose co-transporter 2 inhibitor dapagliflozin decreases haemoglobin A1c (HbA1c), body weight, blood pressure (BP) and urinary albumin:creatinine ratio (UACR) in patients with type 2 diabetes. The efficacy and safety of this drug have not been properly defined in patients with type 2 diabetes and Stages 3b–4 chronic kidney disease (CKD). Methods In a pooled analysis of 11 phase 3 randomized controlled clinical trials, we determined least square mean changes in HbA1c, body weight, BP, estimated glomerular filtration rate (eGFR) and UACR over 102 weeks in patients with type 2 diabetes and an eGFR between 12 to less than 45 mL/min/1.73 m2 receiving placebo (n = 69) or dapagliflozin 5 or 10 mg (n = 151). Effects on UACR were determined in a subgroup of patients with baseline UACR ≥30 mg/g (n = 136). Results Placebo-corrected changes in HbA1c with dapagliflozin 5 and 10 mg were 0.03% [95% confidence interval (CI) −0.3–0.3] and 0.03% (95% CI −0.2–0.3) during the overall 102-week period. Dapagliflozin 5 and 10 mg compared with placebo reduced UACR by − 47.1% (95% CI −64.8 to − 20.6) and −38.4% (95% CI −57.6 to − 10.3), respectively. Additionally, dapagliflozin 5 and 10 mg compared with placebo reduced BP and body weight. eGFR increased with placebo during the first 4 weeks but did not change with dapagliflozin. There were no between-group differences in eGFR at the end of follow-up. Adverse events associated with renal function occurred more frequently in the dapagliflozin 10-mg group. These events were mainly asymptomatic increases in serum creatinine. Conclusions Dapagliflozin did not decrease HbA1c in patients with type 2 diabetes and Stages 3b–4 CKD, but decreased UACR, BP and body weight to a clinically meaningful extent. These results support a large outcome trial in this population to confirm long-term safety and efficacy in reducing adverse clinical endpoints.
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Affiliation(s)
- Claire C J Dekkers
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - David C Wheeler
- Centre for Nephrology, University College London, London, UK
| | - C David Sjöström
- Department of Cardiovascular and metabolic diseases, Global Medicines Development, AstraZeneca, Gothenburg, Sweden
| | - Bergur V Stefansson
- Department of Cardiovascular and metabolic diseases, Global Medicines Development, AstraZeneca, Gothenburg, Sweden
| | - Valerie Cain
- Department of Biometrics and Information Sciences, Bogier Clinical and IT Solutions, Raleigh, NC, USA
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Cheng L, Li YY, Hu W, Bai F, Hao HR, Yu WN, Mao XM. Risk of bone fracture associated with sodium–glucose cotransporter-2 inhibitor treatment: A meta-analysis of randomized controlled trials. DIABETES & METABOLISM 2019; 45:436-445. [DOI: 10.1016/j.diabet.2019.01.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/22/2019] [Accepted: 01/25/2019] [Indexed: 02/07/2023]
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Tentolouris A, Vlachakis P, Tzeravini E, Eleftheriadou I, Tentolouris N. SGLT2 Inhibitors: A Review of Their Antidiabetic and Cardioprotective Effects. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E2965. [PMID: 31426529 PMCID: PMC6720282 DOI: 10.3390/ijerph16162965] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/10/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023]
Abstract
Type 2 diabetes mellitus is a chronic metabolic disease associated with high cardiovascular (CV) risk. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are the latest class of antidiabetic medication that inhibit the absorption of glucose from the proximal tubule of the kidney and hence cause glycosuria. Four SGLT2i are currently commercially available in many countries: canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin. SGLT2i reduce glycated hemoglobin by 0.5%-1.0% and have shown favorable effects on body weight, blood pressure, lipid profile, arterial stiffness and endothelial function. More importantly, SGLT2i have demonstrated impressive cardioprotective and renoprotective effects. The main mechanisms underlying their cardioprotective effects have been attributed to improvement in cardiac cell metabolism, improvement in ventricular loading conditions, inhibition of the Na+/H+ exchange in the myocardial cells, alteration in adipokines and cytokines production, as well as reduction of cardiac cells necrosis and cardiac fibrosis. The main adverse events of SGLT2i include urinary tract and genital infections, as well as euglycemic diabetic ketoacidosis. Concerns have also been raised about the association of SGLT2i with lower limb amputations, Fournier gangrene, risk of bone fractures, female breast cancer, male bladder cancer, orthostatic hypotension, and acute kidney injury.
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Affiliation(s)
- Anastasios Tentolouris
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 11527 Athens, Greece
| | - Panayotis Vlachakis
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 11527 Athens, Greece
| | - Evangelia Tzeravini
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 11527 Athens, Greece
| | - Ioanna Eleftheriadou
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 11527 Athens, Greece
| | - Nikolaos Tentolouris
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, 11527 Athens, Greece.
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Newman AA, Grimm NC, Wilburn JR, Schoenberg HM, Trikha SRJ, Luckasen GJ, Biela LM, Melby CL, Bell C. Influence of Sodium Glucose Cotransporter 2 Inhibition on Physiological Adaptation to Endurance Exercise Training. J Clin Endocrinol Metab 2019; 104:1953-1966. [PMID: 30597042 DOI: 10.1210/jc.2018-01741] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 12/21/2018] [Indexed: 12/11/2022]
Abstract
CONTEXT The combination of two beneficial antidiabetes interventions, regular exercise and pharmaceuticals, is intuitively appealing. However, metformin, the most commonly prescribed diabetes medication, attenuates the favorable physiological adaptations to exercise; in turn, exercise may impede the action of metformin. OBJECTIVE We sought to determine the influence of an alternative diabetes treatment, sodium glucose cotransporter 2 (SGLT2) inhibition, on the response to endurance exercise training. DESIGN, PARTICIPANTS, AND INTERVENTION In a randomized, double-blind, repeated measures parallel design, 30 sedentary overweight and obese men and women were assigned to 12 weeks of supervised endurance exercise training, with daily ingestion of either a placebo or SGLT2 inhibitor (dapagliflozin: ≤10 mg/day). OUTCOME MEASUREMENTS AND RESULTS Endurance exercise training favorably modified body mass, body composition (dual-energy x-ray absorptiometry), peak oxygen uptake (graded exercise with indirect calorimetry), responses to standardized submaximal exercise (indirect calorimetry, heart rate, and blood lactate), and skeletal muscle (vastus lateralis) citrate synthase activity (main effects of exercise training, all P < 0.05); SGLT2 inhibition did not influence any of these physiological adaptations (exercise training × treatment interaction, all P > 0.05). However, after endurance exercise training, fasting blood glucose was greater with SGLT2 inhibition, and increased insulin sensitivity (oral glucose tolerance test/Matsuda index) was abrogated with SGLT2 inhibition (exercise training × treatment interaction, P < 0.01). CONCLUSION The efficacy of combining two beneficial antidiabetes interventions, regular endurance exercise and SGLT2 inhibition, was not supported. SGLT2 inhibition blunted endurance exercise training-induced improvements in insulin sensitivity, independent of effects on aerobic fitness or body composition.
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Affiliation(s)
- Alissa A Newman
- Department of Health and Exercise Science, Colorado State University, Fort Collins, Colorado
| | - Nathan C Grimm
- Department of Health and Exercise Science, Colorado State University, Fort Collins, Colorado
| | - Jessie R Wilburn
- Department of Health and Exercise Science, Colorado State University, Fort Collins, Colorado
| | - Hayden M Schoenberg
- Department of Health and Exercise Science, Colorado State University, Fort Collins, Colorado
| | - S Raj J Trikha
- Department of Health and Exercise Science, Colorado State University, Fort Collins, Colorado
| | - Gary J Luckasen
- Medical Center of the Rockies Foundation, University of Colorado Health, Loveland, Colorado
| | - Laurie M Biela
- Department of Health and Exercise Science, Colorado State University, Fort Collins, Colorado
| | - Christopher L Melby
- Department of Food Science and Human Nutrition, Colorado State University, Fort Collins, Colorado
| | - Christopher Bell
- Department of Health and Exercise Science, Colorado State University, Fort Collins, Colorado
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Abstract
INTRODUCTION Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are recommended after metformin for a large spectrum of patients with type 2 diabetes, because of a favorable benefit/risk profile despite a variety of adverse events. AREAS COVERED This narrative review discusses the safety profile of SGLT2is: initial concerns (cardiovascular safety, acute renal failure, hypoglycemia, urinary and genital infections, volume depletion, bladder cancer), further concerns (euglycemic ketoacidosis, bone fractures) and more recent concerns (lower limb amputation, Fournier's gangrene). EXPERT OPINION Overall, the safety profile of SGLT2is is good. The only increased adverse event that was consistently reported in clinical trials and observational studies is genital mycotic infections, with only a borderline increase in urinary tract infections. Among clinical trials, only the CANVAS program reported an unexpected increase in bone fractures and peripheral amputations. A variety of rare adverse events have been described as case reports, including ketoacidosis, amputations and Fournier gangrene, which led to specific warnings by regulatory agencies. Identifying predisposing patient's characteristics and/or precipitating clinical conditions would help prevent the most severe complications. These adverse events should not mask the overall cardiovascular and renal benefit of SGLT2is, especially in patients with type 2 diabetes at high cardiovascular risk.
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Affiliation(s)
- André J Scheen
- a Division of Clinical Pharmacology , Center for Interdisciplinary Research on Medicines (CIRM), Liège University , Liège , Belgium.,b Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine , CHU Liège , Liège , Belgium
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18
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Sertbas M, Sertbas Y, Okuroglu N, Akyildiz AB, Sancak S, Ozdemir A. Effıcacy and safety of dapagliflozin on diabetic patients receiving high-doses of insulin. Pak J Med Sci 2019; 35:399-403. [PMID: 31086522 PMCID: PMC6500813 DOI: 10.12669/pjms.35.2.21] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 12/12/2018] [Accepted: 01/28/2019] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE In this study we aimed to investigate the efficacy and safety of dapagliflozin addition to diabetic patients using high dose insulin. METHODS The current study was carried out in the outpatient diabetic clinics of Fatih Sultan Mehmet Education and Research Hospital. Thirty diabetic patients who were receiving high dose (>0,5U/kg) insulin and oral antidiabetic treatment (other than SGLT 2 inhibitors) were included in this study. Primary end point was the change in HbA1c, insulin doses and serum electrolyte from the addition of dapagliflozin 10 mg to the week 12. RESULTS At the end of three month BMI were obviously decreased from 33.31 ±4.51 to 32.14 ±4.66 (p: 0.001). There was also an evident decrease of insulin requirement from 76 ±23.15 U/kg to 57.60 ±17.61 U/day (p<0.001). As well as the decrease in insulin doses, there was also a significant decline in HbA1c (Δ 1.6 %) and fasting blood glucose levels (Δ68.6 mg/dl) (p<0.001). Among serum electrolyte levels slight but meaningful increase of blood urea nitrogen (BUN) and sodium (Na) levels were seen (p: 0.044 and p: 0.026). There were no significant changes in serum cholesterol levels with electrolytes such as potassium, calcium, phosphorus magnesium and vitamin D (p> 0.05). CONCLUSION In diabetic patients with inadequately controlled glucose regulation despite high-dose insulin therapy, dapagliflozin may be an alternative combination choice to decrease the need of insulin dose and obtain an optimal HbA1c, fasting plasma glucose levels and weight without major side effects.
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Affiliation(s)
- Meltem Sertbas
- Meltem Sertbas, Department of Internal Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Yasar Sertbas
- Yasar Sertbas Department of Internal Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Nalan Okuroglu
- Nalan Okurglu, Department of Internal Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Ali Burkan Akyildiz
- Ali Burkan Akyildiz, Department of Internal Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Seda Sancak
- Seda Sancak, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
| | - Ali Ozdemir
- Ali Ozdemir, Department of Internal Medicine, Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkey
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Kalaitzoglou E, Fowlkes JL, Popescu I, Thrailkill KM. Diabetes pharmacotherapy and effects on the musculoskeletal system. Diabetes Metab Res Rev 2019; 35:e3100. [PMID: 30467957 PMCID: PMC6358500 DOI: 10.1002/dmrr.3100] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/14/2018] [Accepted: 11/19/2018] [Indexed: 12/13/2022]
Abstract
Persons with type 1 or type 2 diabetes have a significantly higher fracture risk than age-matched persons without diabetes, attributed to disease-specific deficits in the microarchitecture and material properties of bone tissue. Therefore, independent effects of diabetes drugs on skeletal integrity are vitally important. Studies of incretin-based therapies have shown divergent effects of different agents on fracture risk, including detrimental, beneficial, and neutral effects. The sulfonylurea class of drugs, owing to its hypoglycemic potential, is thought to amplify the risk of fall-related fractures, particularly in the elderly. Other agents such as the biguanides may, in fact, be osteo-anabolic. In contrast, despite similarly expected anabolic properties of insulin, data suggests that insulin pharmacotherapy itself, particularly in type 2 diabetes, may be a risk factor for fracture, negatively associated with determinants of bone quality and bone strength. Finally, sodium-dependent glucose co-transporter 2 inhibitors have been associated with an increased risk of atypical fractures in select populations, and possibly with an increase in lower extremity amputation with specific SGLT2I drugs. The role of skeletal muscle, as a potential mediator and determinant of bone quality, is also a relevant area of exploration. Currently, data regarding the impact of glucose lowering medications on diabetes-related muscle atrophy is more limited, although preclinical studies suggest that various hypoglycemic agents may have either aggravating (sulfonylureas, glinides) or repairing (thiazolidinediones, biguanides, incretins) effects on skeletal muscle atrophy, thereby influencing bone quality. Hence, the therapeutic efficacy of each hypoglycemic agent must also be evaluated in light of its impact, alone or in combination, on musculoskeletal health, when determining an individualized treatment approach. Moreover, the effect of newer medications (potentially seeking expanded clinical indication into the pediatric age range) on the growing skeleton is largely unknown. Herein, we review the available literature regarding effects of diabetes pharmacotherapy, by drug class and/or by clinical indication, on the musculoskeletal health of persons with diabetes.
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Affiliation(s)
- Evangelia Kalaitzoglou
- University of Kentucky Barnstable Brown Diabetes Center Department of Pediatrics, University of Kentucky College of Medicine, Lexington, KY, USA
| | - John L Fowlkes
- University of Kentucky Barnstable Brown Diabetes Center Department of Pediatrics, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Iuliana Popescu
- University of Kentucky Barnstable Brown Diabetes Center Department of Pediatrics, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Kathryn M Thrailkill
- University of Kentucky Barnstable Brown Diabetes Center Department of Pediatrics, University of Kentucky College of Medicine, Lexington, KY, USA
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20
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Renoprotective effects of sodium-glucose cotransporter-2 inhibitors. Kidney Int 2018; 94:26-39. [DOI: 10.1016/j.kint.2017.12.027] [Citation(s) in RCA: 194] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/16/2017] [Accepted: 12/13/2017] [Indexed: 02/06/2023]
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Abstract
Cardiovascular disease (CVD) is a major challenge in the management of type 2 diabetes mellitus. Glucose-lowering agents that reduce the risk of major cardiovascular events would be considered a major advance, as recently reported with liraglutide and semaglutide, 2 glucagon-like peptide-1 receptor agonists, and with empagliflozin and canagliflozin, 2 SGLT-2 (sodium-glucose cotransporter type 2) inhibitors, but not with DPP-4 (dipeptidyl peptidase-4) inhibitors. The present review is devoted to CV effects of new oral glucose-lowering agents. DPP-4 inhibitors (gliptins) showed some positive cardiac and vascular effects in preliminary studies, and initial data from phase 2 to 3 clinical trials suggested a reduction in major cardiovascular events. However, subsequent CV outcome trials with alogliptin, saxagliptin, and sitagliptin showed noninferiority but failed to demonstrate any superiority compared with placebo in patients with type 2 diabetes mellitus and high CV risk. An unexpected higher risk of hospitalization for heart failure was reported with saxagliptin. SGLT-2 inhibitors (gliflozins) promote glucosuria, thus reducing glucose toxicity and body weight, and enhance natriuresis, thus lowering blood pressure. Two CV outcome trials in type 2 diabetes mellitus patients mainly in secondary prevention showed remarkable positive results. Empagliflozin in EMPA-REG-OUTCOME (EMPAgliflozin Cardiovascular OUTCOME Events in Type 2 Diabetes Mellitus Patients) reduced major cardiovascular events, CV mortality, all-cause mortality, and hospitalization for heart failure. In CANVAS (Canagliflozin Cardiovascular Assessment Study), the reduction in CV mortality with canagliflozin failed to reach statistical significance despite a similar reduction in major cardiovascular events. The underlying protective mechanisms of SGLT-2 inhibitors remain unknown and both hemodynamic and metabolic explanations have been proposed. CVD-REAL studies (Comparative Effectiveness of Cardiovascular Outcomes in New Users of Sodium-Glucose Cotransporter-2 Inhibitors; with the limitation of an observational approach) suggested that these favorable results may be considered as a class effect shared by all SGLT-2 inhibitors (including dapagliflozin) and be extrapolated to a larger population of patients with type 2 diabetes mellitus in primary prevention. Ongoing CV outcome trials with other DPP-4 (linagliptin) and SGLT-2 (dapagliflozin, ertugliflozin) inhibitors should provide additional information about CV effects of both pharmacological classes.
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Affiliation(s)
- André J Scheen
- From the Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Belgium (A.J.S.)
- Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Belgium (A.J.S.)
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22
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Greydanus DE, Agana M, Kamboj MK, Shebrain S, Soares N, Eke R, Patel DR. Pediatric obesity: Current concepts. Dis Mon 2018; 64:98-156. [DOI: 10.1016/j.disamonth.2017.12.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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23
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Upadhyay J, Polyzos SA, Perakakis N, Thakkar B, Paschou SA, Katsiki N, Underwood P, Park KH, Seufert J, Kang ES, Sternthal E, Karagiannis A, Mantzoros CS. Pharmacotherapy of type 2 diabetes: An update. Metabolism 2018; 78:13-42. [PMID: 28920861 DOI: 10.1016/j.metabol.2017.08.010] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/24/2017] [Accepted: 08/26/2017] [Indexed: 12/22/2022]
Abstract
Type 2 diabetes (T2DM) is a leading cause of morbidity and mortality worldwide and a major economic burden. The prevalence of T2DM is rising, suggesting more effective prevention and treatment strategies are necessary. The aim of this narrative review is to summarize the pharmacologic treatment options available for patients with T2DM. Each therapeutic class is presented in detail, outlining medication effects, side effects, glycemic control, effect on weight, indications and contraindications, and use in selected populations (heart failure, renal insufficiency, obesity and the elderly). We also present representative cost for each antidiabetic category. Then, we provide an individualized guide for initiation and intensification of treatment and discuss the considerations and rationale for an individualized glycemic goal.
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Affiliation(s)
- Jagriti Upadhyay
- Section of Endocrinology, Diabetes and Metabolism, Boston VA Healthcare System, Boston, MA, USA; Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Stergios A Polyzos
- First Department of Pharmacology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Perakakis
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Divisions of Endocrinology and Diabetology, Department of Internal Medicine II, University Hospital of Freiburg, Freiburg, Germany
| | - Bindiya Thakkar
- Section of Endocrinology, Diabetes and Metabolism, Boston VA Healthcare System, Boston, MA, USA
| | - Stavroula A Paschou
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Niki Katsiki
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Patricia Underwood
- Section of Endocrinology, Diabetes and Metabolism, Boston VA Healthcare System, Boston, MA, USA
| | - Kyung-Hee Park
- Department of Family Medicine, Hallym University Sacred Heart Hospital, Gyeonggi-do, Republic of Korea
| | - Jochen Seufert
- Divisions of Endocrinology and Diabetology, Department of Internal Medicine II, University Hospital of Freiburg, Freiburg, Germany
| | - Eun Seok Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Elliot Sternthal
- Section of Endocrinology, Diabetes and Metabolism, Boston VA Healthcare System, Boston, MA, USA
| | - Asterios Karagiannis
- First Department of Pharmacology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos S Mantzoros
- Section of Endocrinology, Diabetes and Metabolism, Boston VA Healthcare System, Boston, MA, USA; Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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24
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Filippatos TD, Tsimihodimos V, Liamis G, Elisaf MS. SGLT2 inhibitors-induced electrolyte abnormalities: An analysis of the associated mechanisms. Diabetes Metab Syndr 2018; 12:59-63. [PMID: 28826578 DOI: 10.1016/j.dsx.2017.08.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 08/07/2017] [Indexed: 12/26/2022]
Abstract
AIMS Sodium-glucose co-transporter 2 (SGLT2) inhibitors are a new class of antidiabetic drugs that affect serum electrolytes levels. The aim of this review is the detailed presentation of the associated mechanisms of the SGLT2 inhibitors-induced electrolyte abnormalities. MATERIALS AND METHODS Eligible trials and relevant articles published in PubMed (last search in July 2017) are included in the review. RESULTS SGLT2 inhibitors induce small increases in serum concentrations of magnesium, potassium and phosphate. The small increase in serum phosphate concentration may result in reduced bone density and increased risk of bone fractures, mainly seen with canagliflozin, but recent meta-analyses did not show increased risk of bone fractures with SGLT2 inhibitors. CONCLUSION The increases in serum electrolytes levels may play a role in the cardiovascular protection that has been recently reported with empagliflozin and canagliflozin.
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Affiliation(s)
- T D Filippatos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece.
| | - V Tsimihodimos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - G Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - M S Elisaf
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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25
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Fixen CW, Fixen DR. Managing and maintaining bone mineral density in diabetes patients with pharmacotherapy. Expert Opin Pharmacother 2017; 18:2001-2006. [PMID: 29172834 DOI: 10.1080/14656566.2017.1410539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The population of patients with osteoporosis and diabetes is increasing as the aging population increases. Loss of bone mineral density occurs in patients with diabetes, but is not always a priority in the practice setting. The aim of this review is to discuss clinical considerations when managing osteoporosis in patients with diabetes. Areas covered: The pathophysiology of decreased bone mineral density in patients with diabetes is discussed. Additionally, diabetic risk factors for fracture, such as hypoglycemia, the National Osteoporosis Foundation recommendations for osteoporosis, and secondary causes of osteoporosis, including disease and medication related causes, are discussed. Furthermore, recommendations for antihyperglycemic agents, thiazolidinediones, canagliflozin, insulin, metformin, and sitagliptin are discussed due to their effects on bone mineral density. Expert opinion: Even though diabetes is an important risk factor for osteoporosis, assessing bone health in diabetic patients is often overlooked. Ensuring adequate prevention and treatment strategies for osteoporosis is vitally important with our diabetic patients as the population ages. T-scores and FRAX scores likely underrepresent a diabetic patients risk for fracture, and this should be taken into consideration in treatment decisions. Future studies are needed to determine optimal pharmacologic treatment of hyperglycemia in this population.
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Affiliation(s)
- Cy W Fixen
- a Denver Veterans Affairs Medical Center , Denver , CO , USA
| | - Danielle R Fixen
- b Department of Clinical Pharmacy , University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences , Aurora , USA
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26
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Adnan Z. Risk stratification of patients with diabetes and the role of sodium glucose co-transporter inhibitors 2 during Ramadan fasting. Diabetes Res Clin Pract 2017; 131:217-218. [PMID: 28778048 DOI: 10.1016/j.diabres.2017.07.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/07/2017] [Accepted: 07/07/2017] [Indexed: 02/02/2023]
Abstract
The month of Ramadan represents a golden opportunity for better management of patients with diabetes not only during Ramadan month, but also through the entire year. Pre Ramadan period is crucial for evaluating and preparing patients with diabetes intending to Fast Ramadan. The risk stratification categories should take into consideration patients with diabetes having specific conditions such as nephrotic syndrome who are predisposed to thrombosis independent to their estimated glomerular filtration rate and glycated haemoglobin. Furthermore, population-specific conditions such as nomadic Bedouins living in remote areas should be considered as part of the very high risk category for fasting Ramadan. Published data regarding the use of sodium glucose co-transporter 2 inhibitors during Ramadan is very limited. Dapagliflozin was the only agent studied during Ramadan. Therefore, it is suggested to categorize this group of agents differently from other agents such as metformin and incretin based therapy studied vastly during Ramadan.
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Affiliation(s)
- Zaina Adnan
- Internal Medicine, Endocrinology, Diabetes and Metabolism, Clalit Medical Services, Israel.
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27
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Alexander RT, Dimke H. Effect of diuretics on renal tubular transport of calcium and magnesium. Am J Physiol Renal Physiol 2017; 312:F998-F1015. [DOI: 10.1152/ajprenal.00032.2017] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 02/22/2017] [Accepted: 02/27/2017] [Indexed: 01/07/2023] Open
Abstract
Calcium (Ca2+) and Magnesium (Mg2+) reabsorption along the renal tubule is dependent on distinct trans- and paracellular pathways. Our understanding of the molecular machinery involved is increasing. Ca2+ and Mg2+ reclamation in kidney is dependent on a diverse array of proteins, which are important for both forming divalent cation-permeable pores and channels, but also for generating the necessary driving forces for Ca2+ and Mg2+ transport. Alterations in these molecular constituents can have profound effects on tubular Ca2+ and Mg2+ handling. Diuretics are used to treat a large range of clinical conditions, but most commonly for the management of blood pressure and fluid balance. The pharmacological targets of diuretics generally directly facilitate sodium (Na+) transport, but also indirectly affect renal Ca2+ and Mg2+ handling, i.e., by establishing a prerequisite electrochemical gradient. It is therefore not surprising that substantial alterations in divalent cation handling can be observed following diuretic treatment. The effects of diuretics on renal Ca2+ and Mg2+ handling are reviewed in the context of the present understanding of basal molecular mechanisms of Ca2+ and Mg2+ transport. Acetazolamide, osmotic diuretics, Na+/H+ exchanger (NHE3) inhibitors, and antidiabetic Na+/glucose cotransporter type 2 (SGLT) blocking compounds, target the proximal tubule, where paracellular Ca2+ transport predominates. Loop diuretics and renal outer medullary K+ (ROMK) inhibitors block thick ascending limb transport, a segment with significant paracellular Ca2+ and Mg2+ transport. Thiazides target the distal convoluted tubule; however, their effect on divalent cation transport is not limited to that segment. Finally, potassium-sparing diuretics, which inhibit electrogenic Na+ transport at distal sites, can also affect divalent cation transport.
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Affiliation(s)
- R. Todd Alexander
- Membrane Protein Disease Research Group, Department of Physiology, University of Alberta, Edmonton, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Canada; and
| | - Henrik Dimke
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
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28
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Bundhun PK, Janoo G, Huang F. Adverse drug events observed in patients with type 2 diabetes mellitus treated with 100 mg versus 300 mg canagliflozin: a systematic review and meta-analysis of published randomized controlled trials. BMC Pharmacol Toxicol 2017; 18:19. [PMID: 28411624 PMCID: PMC5392384 DOI: 10.1186/s40360-017-0126-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 02/28/2017] [Indexed: 12/15/2022] Open
Abstract
Background Nowadays, canagliflozin monotherapy, or in combination with other oral hypoglycemic agents (OHAs), is often administered in patients who are treated for type 2 diabetes mellitus (T2DM). Therefore, we aimed to systematically compare the adverse drugs events (AEs) which were associated with 100 mg versus 300 mg canagliflozin respectively, using a large number of randomized patients with T2DM which were obtained from published trials. Methods Randomized controlled trials (RCTs) comparing 100 mg versus 300 mg canagliflozin in patients who were treated for T2DM were searched from electronic databases. AEs reported during a follow up period ranging from 12 to 104 weeks were considered as the clinical endpoints in this analysis. We calculated odds ratios (OR) with 95% confidence intervals (CIs) and the analyses were carried out by RevMan 5 · 3 software. Results Ten trials involving a total number of 5394 patients (2604 patients who were treated with 100 mg canagliflozin and 2790 patients who were treated with 300 mg canagliflozin) were included. The current results showed that serious AEs were not significantly higher in patients who were treated by 300 mg canagliflozin, with OR: 1.01, 95% CI: 0.79–1.29; P = 0.93. Also, a similar rate of death was observed in patients who were treated by either 100 or 300 mg canagliflozin with OR: 1.13, 95% CI: 0.43–2.94; P = 0.80. Urinary tract infections, postural dizziness and hypoglycemia were also similarly manifested, with OR: 0.93, 95% CI: 0.70–1.23; P = 0.61, OR: 1.51, 95% CI: 0.42–5.37; P = 0.53 and OR: 0.96, 95% CI: 0.81–1.13; P = 0.60 respectively. However, drug discontinuation due to AEs significantly favored 100 mg canagliflozin only during this unequal follow-up period with OR: 1.35, 95% CI: 1.06–1.72; P = 0.01, but it was not significantly different when trials with similar follow-up periods were analyzed. Conclusion 300 mg canagliflozin was not associated with significantly higher adverse events compared to 100 mg canagliflozin in those patients who were treated for T2DM. However, because this result was partly affected by other anti-diabetic medications which were included in the treatment regimen, further studies based on patients who were treated strictly on canagliflozin monotherapy should be recommended to completely solve this issue.
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Affiliation(s)
- Pravesh Kumar Bundhun
- Institute of Cardiovascular Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People's Republic of China
| | - Girish Janoo
- Guangxi Medical University, Nanning, Guangxi, 530021, People's Republic of China
| | - Feng Huang
- Institute of Cardiovascular Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People's Republic of China.
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