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Zhao H, Liu Y, Liu M, Xu Y, Ling Q, Lin W, Zhang J, Yan Z, Ma J, Li W, Zhao Y, Yu P, Liu X, Wang J. Clinical Outcomes with GLP-1 Receptor Agonists in Patients with Heart Failure: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Drugs 2023; 83:1293-1307. [PMID: 37639180 DOI: 10.1007/s40265-023-01932-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) reduce the risk of major adverse cardiovascular events (MACE) in patients with type 2 diabetes mellitus (T2DM). However, there remains uncertainty about the efficiency of GLP-1 RAs in patients with heart failure (HF). METHODS Randomized placebo-controlled trials (RCTs) that reported the effect of GLP-1 RAs on prognosis in patients with HF were identified by searching databases. The primary outcome was defined as MACE. Trail Sequential Analysis (TSA) was used to evaluate the reality and authenticity. RESULTS Nine RCTs involving 8920 patients with HF were included. GLP-1 RAs significantly reduced the risk of MACE compared with placebo (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.77-0.98) in HF coexisting with T2DM. The benefit was not observed in all-cause death (HR 0.99, 95% CI 0.84-1.15), hospitalization for heart failure (HR 1.04, 95% CI 0.89-1.22), cardiovascular death (HR 0.95, 95% CI 0.79-1.16), myocardial infarction (HR 0.88, 95% CI 0.71-1.08), stroke (HR 1.03, 95% CI 0.75-1.43) and death or hospitalization for HF (HR 1.07, 95% CI 0.78-1.46). GLP-1 RAs did not improve the change in LVEF (mean difference [MD]): - 0.86, p = 0.12, left-ventricular end-diastolic volume (LVEDV) (MD: 3.54, p = 0.11), left-ventricular end-systolic volume (LVESV) (MD: 2.78, p = 0.07) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) (MD: - 140.36, p = 0.08). However, GLP-1 RAs significantly increased the change in the 6-min walk test (MWT) distance (MD: 19.74, p = 0.002). In the subgroup analyses, human GLP-1 RAs, but not nonhuman GLP-1 RAs, reduced the risk of MACE in patients with HF (p interaction = 0.11). Grading of Recommendations Assessment, Development and Evaluation (GRADE) showed moderate certainty for MACE, all-cause death and hospitalization for HF. Trail Sequential Analysis revealed that there may be a high possibility of false positive results for MACE. CONCLUSION Compared with placebo, GLP-1 RAs may reduce the risk of MACE in patients with HF coexisting with T2DM, with a more significant efficiency of human GLP-1 RAs. More RCTs are needed to assess the cardiovascular benefits of GLP-1 RAs in HF, regardless of T2DM. REGISTRATION The protocol for this meta-analysis is registered on PROSPERO [CRD42022357886].
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Affiliation(s)
- Huilei Zhao
- Department of Anesthesiology, The Third Hospital of Nanchang, Nanchang, Jiangxi, China
| | - Yang Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Menglu Liu
- Department of Cardiology, Seventh People's Hospital of Zhengzhou, Zhengzhou, China
| | - Yi Xu
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Qin Ling
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Weichun Lin
- Department of Gastroenterology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jing Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Zhiwei Yan
- Department of Sports Rehabilitation, Shenyang Sport University, Shenyang, Liaoning, China
- Provincial University Key Laboratory of Sport and Health Science, School of Physical Education and Sport Sciences, Fujian Normal University, Fuzhou, China
| | - Jianyong Ma
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Weiguang Li
- Department of Rehabilitation, Liaoning Province Jinqiu Hospital, Shenyang, Liaoning, China
| | - Yujie Zhao
- Department of Cardiology, Seventh People's Hospital of Zhengzhou, Zhengzhou, China
| | - Peng Yu
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.
| | - Xiao Liu
- Department of Cardiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
- Guangdong Provincial Key Laboratory of Arrhythmia and Electrophysiology, Sun Yat-Sen University, Guangzhou, Guangdong, China.
- Guangzhou Key Laboratory of Molecular Mechanism and Translation in Major Cardiovascular Disease, Guangzhou, Guangdong, China.
| | - Jingfeng Wang
- Department of Cardiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Arrhythmia and Electrophysiology, Sun Yat-Sen University, Guangzhou, Guangdong, China
- Guangzhou Key Laboratory of Molecular Mechanism and Translation in Major Cardiovascular Disease, Guangzhou, Guangdong, China
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Nguyen BN, Nguyen L, Mital S, Bugden S, Nguyen HV. Comparative efficacy of sodium-glucose co-transporter-2 inhibitors, glucagon-like peptide-1 receptor agonists and non-steroidal mineralocorticoid receptor antagonists in chronic kidney disease and type 2 diabetes: A systematic review and network meta-analysis. Diabetes Obes Metab 2023; 25:1614-1623. [PMID: 36751968 DOI: 10.1111/dom.15009] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/04/2023] [Accepted: 02/04/2023] [Indexed: 02/09/2023]
Abstract
AIM To compare the relative efficacy of sodium-glucose co-transporter 2 inhibitors (SGLT-2is), glucagon-like peptide-1 receptor agonists (GLP-1RAs) and non-steroidal mineralocorticoid receptor antagonists (nsMRAs) in improving the cardiovascular and renal outcomes in patients with type 2 diabetes (T2D) and chronic kidney disease (CKD). MATERIALS AND METHODS We searched PubMed, Embase and Cochrane Library from inception through 25 November 2022. We selected randomized controlled trials that studied patients with CKD and T2D with a follow-up of at least 24 weeks and compared SGLT-2is, GLP-1RAs and nsMRAs with each other and with placebo. Primary outcomes were major adverse cardiovascular events (MACE) and composite renal outcomes (CRO). Secondary outcomes were cardiovascular death, all-cause death, stroke, myocardial infarction and heart failure hospitalization (HFH). A frequentist approach was used to pool risk ratios (RRs) with 95% confidence intervals (CIs). RESULTS Twenty-nine studies with 50 938 participants for MACE and 49 965 participants for CRO were included. SGLT-2is did not significantly reduce MACE but were associated with significantly lower risks of CRO compared with GLP-1RAs (RR, 0.77; 95% CI, 0.64-0.91; P = .003) and nsMRAs (RR, 0.78; 95% CI, 0.68-0.90; P = .001). Compared with GLP-1RAs and nsMRAs, SGLT-2is significantly reduced risks of HFH by 31% (RR, 0.69; 95% CI, 0.55-0.88; P = .002) and 22% (RR, 0.78; 95% CI, 0.63-0.95; P = .016), respectively, but did not significantly reduce other secondary outcomes. There were no significant differences between GLP-1RAs and nsMRAs in lowering all outcomes. CONCLUSIONS SGLT-2is were associated with better cardiorenal protection than GLP-1RAs and nsMRAs in patients with CKD and T2D.
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Affiliation(s)
- Bao-Ngoc Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Le Nguyen
- Department of Pharmacy, General Hospital of Post and Telecommunication, Ho Chi Minh City, Vietnam
| | - Shweta Mital
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shawn Bugden
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Hai V Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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Razavi M, Wei YY, Rao XQ, Zhong JX. DPP-4 inhibitors and GLP-1RAs: cardiovascular safety and benefits. Mil Med Res 2022; 9:45. [PMID: 35986429 PMCID: PMC9392232 DOI: 10.1186/s40779-022-00410-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 08/08/2022] [Indexed: 11/10/2022] Open
Abstract
Glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors are commonly used treatments for patients with type 2 diabetes mellitus (T2DM). Both anti-diabetic treatments function by playing key modulatory roles in the incretin system. Though these drugs have been deemed effective in treating T2DM, the Food and Drug Administration (FDA) and some members of the scientific community have questioned the safety of these therapeutics relative to important cardiovascular endpoints. As a result, since 2008, the FDA has required all new drugs for glycemic control in T2DM patients to demonstrate cardiovascular safety. The present review article strives to assess the safety and benefits of incretin-based therapy, a new class of antidiabetic drug, on the health of patient cardiovascular systems. In the process, this review will also provide a physiological overview of the incretin system and how key components function in T2DM.
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Affiliation(s)
- Michael Razavi
- Tulane University School of Medicine, New Orleans, LA, 70112, USA
| | - Ying-Ying Wei
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430032, China
| | - Xiao-Quan Rao
- Department of Cardiovascular Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430032, China.
| | - Ji-Xin Zhong
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430032, China. .,Institute of Allergy and Clinical Immunology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430032, China.
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Cardiovascular and Renal Effectiveness of GLP-1 Receptor Agonists vs. Other Glucose-Lowering Drugs in Type 2 Diabetes: A Systematic Review and Meta-Analysis of Real-World Studies. Metabolites 2022; 12:metabo12020183. [PMID: 35208256 PMCID: PMC8879165 DOI: 10.3390/metabo12020183] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular outcome trials (CVOT) showed that treatment with glucagon-like peptide-1 receptor agonists (GLP-1RA) is associated with significant cardiovascular benefits. However, CVOT are scarcely representative of everyday clinical practice, and real-world studies could provide clinicians with more relatable evidence. Here, literature was thoroughly searched to retrieve real-world studies investigating the cardiovascular and renal outcomes of GLP-1RA vs. other glucose-lowering drugs and carry out relevant meta-analyses thereof. Most real-world studies were conducted in populations at low cardiovascular and renal risk. Of note, real-world studies investigating cardio-renal outcomes of GLP-1RA suggested that initiation of GLP-1RA was associated with a greater benefit on composite cardiovascular outcomes, MACE (major adverse cardiovascular events), all-cause mortality, myocardial infarction, stroke, cardiovascular death, peripheral artery disease, and heart failure compared to other glucose-lowering drugs with the exception of sodium-glucose transporter-2 inhibitors (SGLT-2i). Initiation of SGLT-2i and GLP-1RA yielded similar effects on composite cardiovascular outcomes, MACE, stroke, and myocardial infarction. Conversely, GLP-1RA were less effective on heart failure prevention compared to SGLT-2i. Finally, the few real-world studies addressing renal outcomes suggested a significant benefit of GLP-1RA on estimated glomerular filtration rate (eGFR) reduction and hard renal outcomes vs. active comparators except SGLT-2i. Further real-world evidence is needed to clarify the role of GLP-1RA in cardio-renal protection among available glucose-lowering drugs.
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Sciacqua A, Succurro E, Armentaro G, Miceli S, Pastori D, Rengo G, Sesti G. Pharmacological treatment of type 2 diabetes in elderly patients with heart failure: randomized trials and beyond. Heart Fail Rev 2021; 28:667-681. [PMID: 34859336 DOI: 10.1007/s10741-021-10182-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2021] [Indexed: 12/18/2022]
Abstract
Heart failure (HF) and type 2 diabetes mellitus (T2DM) represent two important public health problems, and despite improvements in the management of both diseases, they are responsible for high rates of hospitalizations and mortality. T2DM accelerates physiological cardiac aging through hyperglycemia and hyperinsulinemia. Thus, HF and T2DM are chronic diseases widely represented in elderly people who often are affected by numerous comorbidities with important functional limitations making it difficult to apply the current guidelines. Several antidiabetic drugs should be used with caution in elderly individuals with T2DM. For instance, sulfonylureas should be avoided due to the risk of hypoglycemia associated with its use. Insulin should be used with caution because it is associated with higher risk of hypoglycemia, and may determine fluid retention which can lead to worsening of HF. Thiazolindinediones should be avoided due to the increased risk of fluid retention and HF. Biguanides may lead to a slightly increased risk of lactic acidosis in particular in elderly individuals with impaired renal function. Dipeptidyl peptidase 4 (DPP-4) inhibitors are safe having few side effects, minimal risk of hypoglycemia, and a neutral effect on cardiovascular (CV) outcome, even if it has been reported that saxagliptin treatment is associated with increased risk of hospitalizations for HF (hHF). Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have shown a CV protection without a significant reduction in hHF. On the other hand, sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown a significant improvement in CV outcome, with a strong reduction of hHF and a positive impact on renal damage progression. However, it is necessary to consider the possible some side effects related to their use in elderly individuals including hypotension, bone fractures, and ketoacidosis.It is important to remark that elderly patients, in particular the very elderly, are not sufficiently represented in the trials; thus, the management and treatment of elderly diabetic patients with HF should be mainly based on the integration of scientific evidence with clinical judgment and patients' condition, with respect to the dignity and quality of life.
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Affiliation(s)
- Angela Sciacqua
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Campus Universitario di Germaneto, V.le Europa, 88100, Catanzaro, Italy.
| | - Elena Succurro
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Campus Universitario di Germaneto, V.le Europa, 88100, Catanzaro, Italy
| | - Giuseppe Armentaro
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Campus Universitario di Germaneto, V.le Europa, 88100, Catanzaro, Italy
| | - Sofia Miceli
- Department of Medical and Surgical Sciences, University Magna Græcia of Catanzaro, Campus Universitario di Germaneto, V.le Europa, 88100, Catanzaro, Italy
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Rengo
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
- Istituti Clinici Scientifici (ICS) Maugeri SPA, Società Benefit, IRCCS, Pavia, Italy
- Istituto Scientifico di Telese Terme, Telese, Terme, Italy
| | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, University Rome-Sapienza, Rome, Italy
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Morieri ML, Targher G, Lapolla A, D'Ambrosio M, Tadiotto F, Rigato M, Frison V, Paccagnella A, Simioni N, Avogaro A, Fadini GP. Changes in markers of hepatic steatosis and fibrosis in patients with type 2 diabetes during treatment with glucagon-like peptide-1 receptor agonists. A multicenter retrospective longitudinal study. Nutr Metab Cardiovasc Dis 2021; 31:3474-3483. [PMID: 34629258 DOI: 10.1016/j.numecd.2021.08.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/16/2021] [Accepted: 08/31/2021] [Indexed: 02/06/2023]
Abstract
AIMS Metabolic dysfunction-associated fatty liver disease (MAFLD) is common in people with type 2 diabetes (T2D) and can progress to advanced fibrosis and cirrhosis. In this retrospective study, we explored the longitudinal changes in markers of hepatic steatosis and fibrosis during T2D treatment with glucagon-like peptide-1 receptor agonists (GLP-1RAs). METHODS We analysed observational data from six diabetes outpatient clinics. In the whole T2D population, we calculated the hepatic steatosis index (HSI), which we previously validated against liver ultrasonography, and the Fibrosis (Fib)-4 index. We then identified patients who initiated a GLP-1RA from 2010 to 2018 and for whom data were available to evaluate changes in both HSI and Fib-4 scores over 24 months. RESULTS From 83,116 outpatients with T2D, 41,302 (49.7%) had complete data for calculating HSI and Fib-4. Most of these T2D patients (∼70%) had MAFLD (defined as HSI>36), 9.7% of whom had advanced fibrosis based on Fib-4 thresholds. Patients with low compared to high risk of advanced fibrosis were 5-times more likely to be treated with GLP-1RA. In 535 patients who initiated a GLP-1RA, the prevalence of MAFLD based on HSI declined significantly at 6 and 24 months, but Fib-4 categories did not. HSI improved significantly only in patients receiving human-based but not exendin-based GLP-1RA, while patients concomitantly receiving metformin had less worsening in Fib-4 categories. CONCLUSIONS MAFLD is very common among outpatients with T2D (∼70%) and the estimated prevalence of advanced fibrosis was ∼10%. Treatment with GLP-1RAs significantly improved MAFLD, but not MAFLD-associated advanced fibrosis.
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Affiliation(s)
| | - Giovanni Targher
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Annunziata Lapolla
- Department of Medicine, University of Padova, Padua, Italy; Diabetology Service ULSS6 Padua, Italy
| | | | | | | | - Vera Frison
- Internal Medicine and Diabetology Service, ULSS6, Cittadella, Italy
| | | | - Natalino Simioni
- Internal Medicine and Diabetology Service, ULSS6, Cittadella, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padua, Italy
| | - Gian Paolo Fadini
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy.
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7
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Longato E, Di Camillo B, Sparacino G, Tramontan L, Avogaro A, Fadini GP. Cardiovascular outcomes after initiating GLP-1 receptor agonist or basal insulin for the routine treatment of type 2 diabetes: a region-wide retrospective study. Cardiovasc Diabetol 2021; 20:222. [PMID: 34774054 PMCID: PMC8590792 DOI: 10.1186/s12933-021-01414-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/04/2021] [Indexed: 01/17/2023] Open
Abstract
Aim We aimed to compare cardiovascular outcomes of patients with type 2 diabetes (T2D) who initiated GLP-1 receptor agonists (GLP-1RA) or basal insulin (BI) under routine care. Methods We accessed the administrative claims database of the Veneto Region (Italy) to identify new users of GLP-1RA or BI in 2014–2018. Propensity score matching (PSM) was implemented to obtain two cohorts of patients with superimposable characteristics. The primary endpoint was the 3-point major adverse cardiovascular events (3P-MACE). Secondary endpoints included 3P-MACE components, hospitalization for heart failure, revascularizations, and adverse events. Results From a background population of 5,242,201 citizens, 330,193 were identified as having diabetes. PSM produced two very well matched cohorts of 4063 patients each, who initiated GLP-1RA or BI after an average of 2.5 other diabetes drug classes. Patients were 63-year-old and only 15% had a baseline history of cardiovascular disease. During a median follow-up of 24 months in the intention-to-treat analysis, 3P-MACE occurred less frequently in the GLP-1RA cohort (HR versus BI 0.59; 95% CI 0.50–0.71; p < 0.001). All secondary cardiovascular endpoints were also significantly in favor of GLP-1RA. Results were confirmed in the as-treated approach and in several stratified analyses. According to the E-value, confounding by unmeasured variables were unlikely to entirely explain between-group differences in cardiovascular outcomes. Conclusions Patients with T2D who initiated a GLP-1RA experienced far better cardiovascular outcomes than did matched patients who initiated a BI in the same healthcare system. These finding supports prioritization of GLP-1RA as the first injectable regimen for the management of T2D. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01414-3.
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Affiliation(s)
- Enrico Longato
- Department of Information Engineering, University of Padova, 35100, Padova, Italy
| | - Barbara Di Camillo
- Department of Information Engineering, University of Padova, 35100, Padova, Italy
| | - Giovanni Sparacino
- Department of Information Engineering, University of Padova, 35100, Padova, Italy
| | - Lara Tramontan
- Arsenàl.IT, Veneto's Research Centre for eHealth Innovation, 31100, Treviso, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100, Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100, Padova, Italy.
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8
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Sharif A. Response to Letter to the Editor. Kidney Int Rep 2021; 6:2935. [PMID: 34805648 PMCID: PMC8589697 DOI: 10.1016/j.ekir.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Sattar N, Lee MMY, Kristensen SL, Branch KRH, Del Prato S, Khurmi NS, Lam CSP, Lopes RD, McMurray JJV, Pratley RE, Rosenstock J, Gerstein HC. Cardiovascular, mortality, and kidney outcomes with GLP-1 receptor agonists in patients with type 2 diabetes: a systematic review and meta-analysis of randomised trials. Lancet Diabetes Endocrinol 2021; 9:653-662. [PMID: 34425083 DOI: 10.1016/s2213-8587(21)00203-5] [Citation(s) in RCA: 535] [Impact Index Per Article: 178.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/08/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND GLP-1 receptor agonists reduce major adverse cardiovascular events (MACE) in patients with type 2 diabetes. However, uncertainty regarding kidney outcomes persists and whether benefits extend to exendin-4-based GLP-1 receptor remains uncertain. We aimed to meta-analyse the most up-to-date evidence on the cardiovascular benefits and risks of GLP-1 receptor agonists from outcome trials in patients with type 2 diabetes. METHODS We did a meta-analysis, including new data from AMPLITUDE-O, using a random effects model to estimate overall hazard ratio (HR) for MACE; its components; all-cause mortality; hospital admission for heart failure; a composite kidney outcome consisting of development of macroalbuminuria, doubling of serum creatinine, or at least 40% decline in estimated glomerular filtration rate (eGFR), kidney replacement therapy, or death due to kidney disease; worsening of kidney function, based on eGFR change; and odds ratios for key safety outcomes (severe hypoglycaemia, retinopathy, pancreatitis, and pancreatic cancer). We also examined MACE outcome in patient subgroups on the basis of MACE incidence rates in the placebo group, presence or absence of cardiovascular disease, HbA1c level, trial duration, treatment dosing interval, structural homology to human GLP-1 or exendin-4, BMI, age, and eGFR. We searched PubMed for eligible trials reporting MACE (ie, cardiovascular death, myocardial infarction, or stroke), up to June 9, 2021. We meta-analysed data from published randomised placebo-controlled trials testing either injectable or oral GLP-1 receptor agonists in patients with type 2 diabetes. We restricted the search to trials of more than 500 patients with a primary outcome that included cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. This meta-analysis was registered on PROSPERO, CRD42021259711. FINDINGS Of 98 articles screened, eight trials comprising 60 080 patients fulfilled the prespecified criteria and were included. Overall, GLP-1 receptor agonists reduced MACE by 14% (HR 0·86 [95% CI 0·80-0·93]; p<0·0001), with no significant heterogeneity across GLP-1 receptor agonist structural homology or eight other examined subgroups (all pinteraction≥0·14). GLP-1 receptor agonists reduced all-cause mortality by 12% (HR 0·88 [95% CI 0·82-0·94]; p=0·0001), hospital admission for heart failure by 11% (HR 0·89 [95% CI 0·82-0·98]; p=0·013), and the composite kidney outcome by 21% (HR 0·79 [95% CI 0·73-0·87]; p<0·0001), with no increase in risk of severe hypoglycaemia, retinopathy, or pancreatic adverse effects. In sensitivity analyses removing the only trial restricted to patients with an acute coronary syndrome (ELIXA), all benefits marginally increased, including the outcome of worsening of kidney function, based on eGFR change (HR 0·82 [95% CI 0·69-0·98]; p=0·030). INTERPRETATION GLP-1 receptor agonists, regardless of structural homology, reduced the risk of individual MACE components, all-cause mortality, hospital admission for heart failure, and worsening kidney function in patients with type 2 diabetes. FUNDING None.
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Affiliation(s)
- Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
| | - Matthew M Y Lee
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Søren L Kristensen
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | | | - Stefano Del Prato
- Department of Clinical & Experimental Medicine, Section of Metabolic Diseases and Diabetes, University of Pisa, Pisa, Italy
| | | | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City and University of Texas Southwestern Medical Center, Dallas TX, USA
| | - Hertzel C Gerstein
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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10
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Longato E, Bonora BM, Di Camillo B, Sparacino G, Tramontan L, Avogaro A, Fadini GP. Outcomes of patients with type 2 diabetes treated with SGLT-2 inhibitors versus DPP-4 inhibitors. An Italian real-world study in the context of other observational studies. Diabetes Res Clin Pract 2021; 179:109024. [PMID: 34454002 DOI: 10.1016/j.diabres.2021.109024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/15/2021] [Accepted: 08/23/2021] [Indexed: 12/26/2022]
Abstract
AIMS We compared cardiovascular outcomes of patients with type 2 diabetes (T2D) receiving sodium glucose cotransporter-2 inhibitors (SGLT2i) or dipeptidyl peptidase-4 inhibitors (DPP4i) under routine care. METHODS From an administrative claims database of >5.2M citizen, we identified patients with T2D who initiated SGLT2i or DPP4i from 2014 to 2018. Patients were matched by propensity scores. The primary outcome was the 3-point major adverse cardiovascular events (3P-MACE). RESULTS After matching, we included 3216 patients/group, with mean age of 63 years, diabetes duration of 8.7 years, and 20% had cardiovascular disease. During a median follow-up of 18 months, the rate of 3P-MACE was lower among patients who initiated SGLT2i versus DPP4i (HR 0.74; 95 %C.I. 0.58-0.94). Initiators of SGLT2i also showed significantly lower rates of myocardial infarction (HR 0.75; 95 %C.I. 0.56-1.00), hospitalization for heart failure (HR 0.44; 95 %C.I. 0.25-0.95) or cardiovascular causes (HR 0.72; 95 %C.I. 0.60-0.87), and all-cause death (HR 0.49; 95 %C.I. 0.25-0.95). Renal failure was less common with SGLT2i than with DPP4i. Results were consistent to those obtained in a meta-analysis of 10 observational studies on ~1.5M patients. CONCLUSIONS Patients with T2D who initiated SGLT2i under routine care had better cardio-renal outcomes and lower all-cause mortality than similar patients who initiated DPP4i.
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Affiliation(s)
- Enrico Longato
- Department of Information Engineering, University of Padova, Via Gradenico, 35100 Padova, Italy
| | | | - Barbara Di Camillo
- Department of Information Engineering, University of Padova, Via Gradenico, 35100 Padova, Italy
| | - Giovanni Sparacino
- Department of Information Engineering, University of Padova, Via Gradenico, 35100 Padova, Italy
| | - Lara Tramontan
- Arsenàl.IT, Veneto's Research Centre for eHealth Innovation, Viale Guglielmo Oberdan, 5, 31100 Treviso, Italy
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100 Padova, Italy
| | - Gian Paolo Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35100 Padova, Italy; Veneto Institute of Molecular Medicine, 35129 Padua, Italy.
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Halasz G, Piepoli MF. Editors' presentation: focus on pharmacological interventions. Eur J Prev Cardiol 2021; 28:1-4. [PMID: 33755144 DOI: 10.1093/eurjpc/zwaa166] [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: 11/12/2022]
Affiliation(s)
- Geza Halasz
- Cardiac Unit, G. da Saliceto Hospital, AUSL Piacenza and University of Parma, Italy
| | - Massimo F Piepoli
- Cardiac Unit, G. da Saliceto Hospital, AUSL Piacenza and University of Parma, Italy.,Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
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