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Scheen AJ. The current role of SGLT2 inhibitors in type 2 diabetes and beyond: a narrative review. Expert Rev Endocrinol Metab 2023; 18:271-282. [PMID: 37154218 DOI: 10.1080/17446651.2023.2210673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/02/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Sodium-glucose cotransporter 2 inhibitors (SGLT2is, gliflozins), the most recent oral antihyperglycaemic agents, provide a cardiorenal protection, an effect independent of their glucose-lowering potency. AREAS COVERED The antihyperglycaemic potency of SGLT2is was compared with that of dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists, especially when added to metformin monotherapy. Main results of cardiovascular/renal outcome trials with SGLT2is were summarized in different populations: patients with type 2 diabetes mellitus (T2DM) with or without established cardiovascular disease, patients (with or without T2DM) with heart failure (with reduced or preserved left ventricular ejection fraction) and in patients (with or without T2DM) with chronic kidney disease (CKD, including stage 4). Original papers and meta-analyses of these different trials have consistently reported a reduction in hospitalization for heart failure (alone or combined with cardiovascular mortality) and a reduced progression of CKD, with an overall good safety profile. EXPERT OPINION Global use of SGLT2is has increased over time but remains suboptimal despite clinically relevant cardiovascular and renal protection, particularly in patients most likely to benefit. SGLT2is has proven both positive benefit-risk balance and cost-effectiveness in at risk patients. New prospects are expected in other complications, i.e. metabolic-associated fatty liver disease and neurodegenerative disorders.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium
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Paolisso P, Bergamaschi L, Cesaro A, Gallinoro E, Gragnano F, Sardu C, Mileva N, Foà A, Armillotta M, Sansonetti A, Amicone S, Impellizzeri A, Belmonte M, Esposito G, Morici N, Andrea Oreglia J, Casella G, Mauro C, Vassilev D, Galie N, Santulli G, Calabrò P, Barbato E, Marfella R, Pizzi C. Impact of SGLT2-inhibitors on contrast-induced acute kidney injury in Diabetic patients with Acute Myocardial Infarction with and without chronic kidney disease: Insight from SGLT2-I AMI PROTECT Registry. Diabetes Res Clin Pract 2023:110766. [PMID: 37276980 DOI: 10.1016/j.diabres.2023.110766] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/07/2023]
Abstract
AIMS To analyze the association between chronic SGLT2-I treatment and development of contrast-induced acute kidney injury (CI-AKI) in diabetic patients with acute myocardial infarction (AMI) undergoing PCI. METHODS Multicenter international registry of consecutive patients with type 2 diabetes mellitus (T2DM) and AMI undergoing PCI between 2018-2021. The study population was stratified by the presence of chronic kidney disease (CKD) and anti-diabetic therapy at admission (SGLT2-I versus non-SGLT2-I users). RESULTS The study population consisted of 646 patients: 111 SGLT2-I users [28 (25.2%) with CKD] and 535 non-SGLT2-I users [221 (41.3%) with CKD]. The median age was 70 [61-79] years. SGLT2-I users exhibited significantly lower creatinine values at 72h after PCI, both in the non-CKD and CKD stratum. The rate of CI-AKI was 76 (11.8%), significantly lower in SGLT2-I users compared to non-SGLT2-I patients (5.4% vs 13.1%, p=0.022). This finding was also confirmed in patients without CKD (p=0.040). In the CKD cohort, SGLT2-I users maintained significantly lower creatinine values at discharge. The use of SGLT2-I was an independent predictor of reduced rate of CI-AKI (OR 0.356; 95%CI 0.134-0.943, p=0.038). CONCLUSION In T2DM patients with AMI, the use of SGLT2-I was associated with a lower risk of CI-AKI, mostly in patients without CKD.
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Affiliation(s)
- Pasquale Paolisso
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Dept. of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Luca Bergamaschi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum, University of Bologna, Italy
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Emanuele Gallinoro
- Clinical Cardiology and Cardiovascular Imaging Unit, Galeazzi-Sant'Ambrogio Hospital, IRCCS, Milan, Italy, Department of Biomedical and Clinical Sciences, University of Milan, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Niya Mileva
- Medical University of Sofia, Sofia, Bulgaria
| | - Alberto Foà
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum, University of Bologna, Italy
| | - Matteo Armillotta
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum, University of Bologna, Italy
| | - Angelo Sansonetti
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum, University of Bologna, Italy
| | - Sara Amicone
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum, University of Bologna, Italy
| | - Andrea Impellizzeri
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum, University of Bologna, Italy
| | - Marta Belmonte
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium; Dept. of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Giuseppe Esposito
- Dept. of Advanced Biomedical Sciences, University Federico II, Naples, Italy; Interventional Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | - Nuccia Morici
- IRCCS S. Maria Nascente - Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Jacopo Andrea Oreglia
- Interventional Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | | | - Ciro Mauro
- Department of Cardiology, Hospital Cardarelli, Naples, Italy
| | | | - Nazzareno Galie
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum, University of Bologna, Italy
| | - Gaetano Santulli
- Dept. of Advanced Biomedical Sciences, University Federico II, Naples, Italy; International Translational Research and Medical Education (ITME) Consortium, Naples, Italy; Department of Medicine (Division of Cardiology) and Department of Molecular Pharmacology, Wilf Family Cardiovascular Research Institute, Einstein-Sinai Diabetes Research Center, The Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, New York, USA
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Raffaele Marfella
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Carmine Pizzi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum, University of Bologna, Italy.
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Scheen AJ, Bonnet F. Efficacy and safety profile of SGLT2 inhibitors in the elderly: How is the benefit/risk balance? DIABETES & METABOLISM 2023; 49:101419. [PMID: 36640828 DOI: 10.1016/j.diabet.2023.101419] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/13/2023]
Abstract
Type 2 diabetes mellitus (T2DM) is a highly prevalent health condition in the aging population. Older adults with T2DM have higher risks of cardiovascular disease, heart failure (long underestimated) and premature death than those without diabetes. Sodium-glucose cotransporter 2 inhibitors (SGLT2is) have proven their ability to improve cardiovascular prognosis and reduce the risk of hospitalization for heart failure (hHF). However, several adverse events have been reported, whose incidence and severity might be increased in the elderly population. The aims of this comprehensive review were to analyze the benefit-risk ratio of SGLT2i therapy in older patients with T2DM by collecting data from (i) large prospective placebo-controlled cardiovascular outcome trials (including those dedicated to heart failure), using both original publications and dedicated post-hoc analyses across different age groups and (ii) observational cohort studies, describing the effects of SGLT2is versus other glucose-lowering agents on cardiovascular outcomes and hHF in elderly patients or these effects in different age groups. Overall, consistent results showed a similar relative risk reduction in cardiovascular mortality and hHF with SGLT2is independently of age. The absolute risk reduction may be greater in elderly because of a higher background risk in older versus younger patients. Similarly, the safety profile of SGLT2is appeared comparable in older versus younger patients. In conclusion, the benefit/risk balance favors the use of SGLT2is in older patients at risk of cardiovascular disease and/or heart failure. Caution may be required in very old frail patients, especially those exposed to an increased risk of volume depletion.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU, Liege, Belgium; Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liege, Belgium.
| | - Fabrice Bonnet
- Centre Hospitalier Universitaire de Rennes, Université ́ Rennes 1, Rennes, France; INSERM U1018, Villejuif, France
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Scheen AJ. Clinical pharmacology of antidiabetic drugs: What can be expected of their use? Presse Med 2023; 52:104158. [PMID: 36565754 DOI: 10.1016/j.lpm.2022.104158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
The pharmacotherapy of type 2 diabetes mellitus (T2DM) has markedly evolved in the last two decades. Classical antidiabetic agents (sulphonylureas, metformin, insulin) are now in competition with new glucose-lowering medications. Alpha-glucosidase inhibitors and thiazolidinediones (glitazones) were not able to replace older agents, because of insufficient efficacy and/or poor tolerability/safety. In contrast, incretin-based therapies, both dipeptidyl peptidase-4 inhibitors (DPP-4is or gliptins, oral agents) and glucagon-like peptide-1 receptor agonists (GLP-1RAs, subcutaneous injections) are a major breakthrough in the management of T2DM. Because they are not associated with hypoglycaemia and weight gain, DPP-4is tend to replace sulphonylureas as add-on to metformin while GLP-1RAs tend to replace basal insulin therapy after failure of oral therapies. Furthermore, placebo-controlled cardiovascular outcome trials demonstrated neutrality for DPP-4is, but cardiovascular protection for GLP-1RAs in patients with T2DM at high cardiovascular risk. More recently sodium-glucose cotransporter 2 inhibitors (SGLT2is or gliflozins, oral agents) also showed cardiovascular protection, especially a reduction in hospitalization for heart failure, as well as a renal protection in patients with and without T2DM, at high cardiovascular risk, with established heart failure and/or with chronic kidney disease. Thus, GLP-1RAs and SGLT2is are now considered as preferred drugs in T2DM patients with or at high risk of atherosclerotic cardiovascular disease whereas SGLT2is are more specifically recommended in patients with or at risk of heart failure and renal (albuminuric) disease. The management of T2DM is moving from a glucocentric approach to a broader strategy focusing on all risk factors, including overweight/obesity, and to an organ-disease targeted personalized approach.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium; Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium.
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Scheen AJ, Delanaye P. Acute renal injury events in diabetic patients treated with SGLT2 inhibitors: A comprehensive review with a special reference to RAAS blockers. DIABETES & METABOLISM 2021; 48:101315. [PMID: 34910981 DOI: 10.1016/j.diabet.2021.101315] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/03/2021] [Indexed: 01/13/2023]
Abstract
Renin-angiotensin-aldosterone system (RAAS) blockers and sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are two pharmacological classes that proved a remarkable nephroprotective effect, yet a risk of acute kidney injury (AKI) was also pointed out. In 2016, the US Food and Drug Administration recommended caution with the concomitant use of these medications. While the literature devoted to RAAS blockers remained surprisingly limited, numerous articles were published in recent years with SGLT2is. Safety analyses of large prospective cardiorenal trials showed a reduced rather than an increased number of AKI events in patients with type 2 diabetes treated with SGLT2is compared with those treated with placebo, despite the fact that a majority of patients received RAAS blockers at baseline. Interestingly, retrospective observational studies confirmed these reassuring findings in real-life conditions in more heterogeneous and possibly more frailty populations also commonly treated with RAAS blockers by showing a reduced risk of AKI with SGLT2is compared with other glucose-lowering drugs. Currently, there are no evidence of an increased risk of AKI with RAAS blocker-SGLT2i combinations in absence of haemodynamic instability. Several underlying mechanisms could explain a decreased rather than an increased risk of AKI with SGLT2is, including in patients treated with RAAS blockers.
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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 (ULiege), Liège, Belgium.
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège (ULiege), CHU Sart Tilman, Liège, Belgium; Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nîmes, France
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