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Bonnet F, Cooper ME, Kopp L, Fouque D, Candido R. A review of the latest real-world evidence studies in diabetic kidney disease: What have we learned about clinical practice and the clinical effectiveness of interventions? Diabetes Obes Metab 2024. [PMID: 38899425 DOI: 10.1111/dom.15710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/20/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024]
Abstract
Diabetic nephropathy, also known as diabetic kidney disease (DKD), remains a challenge in clinical practice as this is the major cause of kidney failure worldwide. Clinical trials do not answer all the questions raised in clinical practice and real-world evidence provides complementary insights from randomized controlled trials. Real-life longitudinal data highlight the need for improved screening and management of diabetic nephropathy in primary care. Adherence to the recommended guidelines for comprehensive care appears to be suboptimal in clinical practice in patients with DKD. Barriers to the initiation of sodium-glucose cotransporter-2 (SGLT2) inhibitors for patients with DKD persist in clinical practice, in particular for the elderly. Attainment of blood pressure targets often remains an issue. Initiation of glucagon-like peptide-1 receptor agonists (GLP-1RAs) in routine clinical practice is associated with a reduced risk of albuminuria progression and a possible beneficial effect on kidney function. Real-world evidence confirms a beneficial effect of SGLT2 inhibitors on the decline of glomerular filtration, even in the absence of albuminuria, with a lower risk of acute kidney injury events compared to GLP-1RA use. In addition, SGLT2 inhibitors confer a lower risk of hyperkalaemia after initiation compared with dipeptidyl peptidase-4 inhibitors in patients with DKD. Data from a large population indicate that diuretic treatment increases the risk of a significant decline in glomerular filtration rate in the first few weeks of treatment after SGLT2 inhibitor initiation. The perspective for a global approach targeting multifaceted criteria for diabetic individuals with DKD is emerging based on real-world evidence but there is still a long way to go to achieve this goal.
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Affiliation(s)
- Fabrice Bonnet
- Department of Diabetology, CHU de Rennes, Université de Rennes 1, Rennes, France
| | - Mark E Cooper
- Department of Diabetes, School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
| | - Laetitia Kopp
- CarMeN Laboratory, INSERM, INRAE, Claude Bernard Lyon 1 University, Pierre Bénite, France
- Department of Nephrology and Nutrition, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Denis Fouque
- CarMeN Laboratory, INSERM, INRAE, Claude Bernard Lyon 1 University, Pierre Bénite, France
- Department of Nephrology and Nutrition, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Riccardo Candido
- Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
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2
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Ziser KED, Wood S, Tan GSQ, Morton JI, Shaw JE, Bell JS, Ilomaki J. The association between sodium glucose cotransporter-2 inhibitors vs dipeptidyl peptidase-4 inhibitors and renal outcomes in people discharged from hospital with type 2 diabetes: A population-based cohort study. J Diabetes 2024; 16:e13507. [PMID: 38599885 PMCID: PMC11006598 DOI: 10.1111/1753-0407.13507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/29/2023] [Accepted: 11/08/2023] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND We investigated the association between post-hospital discharge use of sodium glucose cotransporter-2 inhibitors (SGLT-2is) compared to dipeptidyl peptidase-4 inhibitors (DPP-4is) and the incidence of hospitalization for acute renal failure (ARF) and chronic kidney disease (CKD) in people with type 2 diabetes. METHODS We conducted a retrospective cohort study using linked hospital and prescription data. Our cohort included people aged ≥30 years with type 2 diabetes discharged from a hospital in Victoria, Australia, from December 2013 to June 2018. We compared new users of SGLT-2is with new users of DPP-4is following discharge. People were followed from first dispensing of a SGLT-2i or DPP-4i to a subsequent hospital admission for ARF or CKD. We used competing risk models with inverse probability of treatment weighting (IPTW) to estimate subhazard ratios. RESULTS In total, 9620 people initiated SGLT-2is and 9962 initiated DPP-4is. The incidence rate of ARF was 12.3 per 1000 person-years (median years of follow-up [interquartile range [IQR] 1.4 [0.7-2.2]) among SGLT-2i initiators and 18.9 per 1000 person-years (median years of follow-up [IQR] 1.7 [0.8-2.6]) among DPP-4i initiators (adjusted subhazard ratio with IPTW 0.78; 95% confidence interval [CI] 0.70-0.86). The incidence rate of CKD was 6.0 per 1000 person-years (median years of follow-up [IQR] 1.4 [0.7-2.2]) among SGLT-2i initiators and 8.9 per 1000 person-years (median years of follow-up [IQR] 1.7 [0.8-2.6]) among DPP-4i initiators (adjusted subhazard ratio with IPTW 0.83; 95% CI 0.73-0.94). CONCLUSIONS Real-world data support using SGLT-2is over DPP-4is for preventing acute and chronic renal events in people with type 2 diabetes.
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Affiliation(s)
- Kate E. D. Ziser
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesMonash UniversityMelbourneVictoriaAustralia
| | - Stephen Wood
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesMonash UniversityMelbourneVictoriaAustralia
| | - George S. Q. Tan
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesMonash UniversityMelbourneVictoriaAustralia
| | - Jedidiah I. Morton
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesMonash UniversityMelbourneVictoriaAustralia
- Clinical Diabetes and Epidemiology, Baker Heart and Diabetes InstituteMelbourneVictoriaAustralia
| | - Jonathan E. Shaw
- Clinical Diabetes and Epidemiology, Baker Heart and Diabetes InstituteMelbourneVictoriaAustralia
| | - J. Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesMonash UniversityMelbourneVictoriaAustralia
| | - Jenni Ilomaki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesMonash UniversityMelbourneVictoriaAustralia
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3
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Fadini GP, Longato E, Morieri ML, Del Prato S, Avogaro A, Solini A. Long-term benefits of dapagliflozin on renal outcomes of type 2 diabetes under routine care: a comparative effectiveness study on propensity score matched cohorts at low renal risk. THE LANCET REGIONAL HEALTH. EUROPE 2024; 38:100847. [PMID: 38328413 PMCID: PMC10847023 DOI: 10.1016/j.lanepe.2024.100847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 12/29/2023] [Accepted: 01/11/2024] [Indexed: 02/09/2024]
Abstract
Background Despite the overall improvement in care, people with type 2 diabetes (T2D) experience an excess risk of end-stage kidney disease. We evaluated the long-term effectiveness of dapagliflozin on kidney function and albuminuria in patients with T2D. Methods We included patients with T2D who initiated dapagliflozin or comparators from 2015 to 2020. Propensity score matching (PSM) was performed to balance the two groups. The primary endpoint was the change in estimated glomerular filtration rate (eGFR) from baseline to the end of observation. Secondary endpoints included changes in albuminuria and loss of kidney function. Findings We analysed two matched groups of 6197 patients each. The comparator group included DPP-4 inhibitors (40%), GLP-1RA (22.3%), sulphonylureas (16.1%), pioglitazone (8%), metformin (5.8%), or acarbose (4%). Only 6.4% had baseline eGFR <60 ml/min/1.73 m2 and 15% had UACR >30 mg/g. During a mean follow-up of 2.5 year, eGFR declined significantly less in the dapagliflozin vs comparator group by 1.81 ml/min/1.73 m2 (95% C.I. from 1.13 to 2.48; p < 0.0001). The mean eGFR slope was significantly less negative in the dapagliflozin group by 0.67 ml/min/1.73 m2/year (95% C.I. from 0.47 to 0.88; p < 0.0001). Albuminuria declined significantly in new-users of dapagliflozin within 6 months and remained on average 44.3 mg/g lower (95% C.I. from -66.9 to -21.7; p < 0.0001) than in new-users of comparators. New-users of dapagliflozin had significantly lower rates of new-onset CKD, loss of kidney function, and a composite renal outcome. Results were confirmed for all SGLT2 inhibitors, in patients without baseline CKD, and when GLP-1RA were excluded from comparators. Interpretation Initiating dapagliflozin improved kidney function outcomes and albuminuria in patients with T2D and a low renal risk. Funding Funded by the Italian Diabetes Society and partly supported by a grant from AstraZeneca.
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Affiliation(s)
- Gian Paolo Fadini
- Division of Metabolic Diseases, Department of Medicine, University of Padova, 35128 Padova, Italy
- Laboratory of Experimental Diabetology, Veneto Institute of Molecular Medicine, 35128 Padova, Italy
| | - Enrico Longato
- Department of Information Engineering, University of Padova, 35100 Padua, Italy
| | - Mario Luca Morieri
- Division of Metabolic Diseases, Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Stefano Del Prato
- Department of Clinical & Experimental Medicine, University of Pisa and Sant’Anna School of Advanced Studies, 56126 Pisa, Italy
| | - Angelo Avogaro
- Division of Metabolic Diseases, Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Italy
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4
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Melzer Cohen C, Schechter M, Rozenberg A, Yanuv I, Sehtman-Shachar DR, Fishkin A, Rosenzweig D, Chodick G, Karasik A, Mosenzon O. Long-Term, Real-World Kidney Outcomes with SGLT2i versus DPP4i in Type 2 Diabetes without Cardiovascular or Kidney Disease. Clin J Am Soc Nephrol 2023; 18:1153-1162. [PMID: 37382938 PMCID: PMC10564349 DOI: 10.2215/cjn.0000000000000218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/11/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Contemporary guidelines recommend the use of sodium-glucose cotransporter 2 inhibitors (SGLT2is) independently of glycemic control in patients with type 2 diabetes and those with kidney disease, with heart failure, or at high risk of cardiovascular disease. Using a large Israeli database, we assessed whether long-term use of SGLT2is versus dipeptidyl peptidase 4 inhibitors (DPP4is) is associated with kidney benefits in patients with type 2 diabetes overall and in those without evidence of cardiovascular or kidney disease. METHODS Patients with type 2 diabetes who initiated SGLT2is or DPP4is between 2015 and 2021 were propensity score-matched (1:1) according to 90 parameters. The kidney-specific composite outcome included confirmed ≥40% decline in eGFR or kidney failure. The kidney-or-death outcome included also all-cause mortality. Risks of outcomes were assessed using Cox proportional hazard regression models. The between-group difference in eGFR slope was also assessed. Analyses were repeated in patients' subgroup lacking evidence of cardiovascular or kidney disease. RESULTS Overall, 19,648 propensity score-matched patients were included; 10,467 (53%) did not have evidence of cardiovascular or kidney disease. Median follow-up was 38 months (interquartile range, 22-55). The composite kidney-specific outcome occurred at an event rate of 6.9 versus 9.5 events per 1000 patient-years with SGLT2i versus DPP4i. The respective event rates of the kidney-or-death outcome were 17.7 versus 22.1. Compared with DPP4is, initiation of SGLT2is was associated with a lower risk for the kidney-specific (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.61 to 0.86; P < 0.001) and kidney-or-death (HR, 0.80; 95% CI, 0.71 to 0.89; P < 0.001) outcomes. The respective HRs (95% CI) in those lacking evidence of cardiovascular or kidney disease were 0.67 (0.44 to 1.02) and 0.77 (0.61 to 0.97). Initiation of SGLT2is versus DPP4is was associated with mitigation of the eGFR slope overall and in those lacking evidence of cardiovascular or kidney disease (mean between-group differences 0.49 [95% CI, 0.35 to 0.62] and 0.48 [95% CI, 0.32 to 0.64] ml/min per 1.73 m 2 per year, respectively). CONCLUSIONS Long-term use of SGLT2is versus DPP4is in a real-world setting was associated with mitigation of eGFR loss in patients with type 2 diabetes, even in those lacking evidence of cardiovascular or kidney disease at baseline.
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Affiliation(s)
- Cheli Melzer Cohen
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Meir Schechter
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dvora R. Sehtman-Shachar
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alisa Fishkin
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Gabriel Chodick
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
- School of Public Health Sackler, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avraham Karasik
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Gorgojo-Martinez JJ, Brito-Sanfiel M, Antón-Bravo T, Galdón Sanz-Pastor A, Wong-Cruz J, Gargallo Fernández MA. Predictive Factors of Renal Function Decline in Patients with Type 2 Diabetes Treated with Canagliflozin in the Real-Wecan Study. J Clin Med 2022; 11:jcm11195622. [PMID: 36233490 PMCID: PMC9573752 DOI: 10.3390/jcm11195622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/15/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022] Open
Abstract
The Real-WECAN study evaluated the real-life effectiveness and safety of canagliflozin 100 mg daily (initiated in SGLT-2 inhibitors naïve patients) and canagliflozin 300 mg daily (switching from canagliflozin 100 mg or other SGLT-2 inhibitors) in individuals with type 2 diabetes. The objectives of this sub-analysis were to estimate the eGFR slope over the follow-up period and to identify predictive factors of eGFR decline in a multiple linear regression analysis. A total of 583 patients (279 on canagliflozin 100 mg and 304 on canagliflozin 300 mg) were included, with median follow-up at 13 months. The patients had a mean age of 60.4 years, HbA1c of 7.76%, BMI of 34.7 kg/m2, eGFR below 60 mL/min/1.73 m2 8.6%, and urine albumin-to-creatinine ratio (UACR) above 30 mg/g 22.8%. eGFR decreased by −1.9 mL/min/1.73 m2 (p < 0.0001) by the end of the study. The mean eGFR slope during the maintenance phase was −0.16 mL/min/1.73 m2 per year. There were no significant differences between both doses of canagliflozin in the eGFR reduction or in the eGFR slope. The best predictive multivariate model of eGFR decline after canagliflozin therapy included age, hypertension, combined hyperlipidemia, heart failure, eGFR and severely increased albuminuria. All these variables except hypertension were independently associated with the outcome. In conclusion, in this real-world study, individuals with older age, combined hyperlipidemia, heart failure, higher eGFR and UACR > 300 mg/g showed a greater decline in their eGFR after canagliflozin treatment.
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Affiliation(s)
- Juan J. Gorgojo-Martinez
- Department of Endocrinology and Nutrition, Hospital Universitario Fundación Alcorcón, Alcorcón, 28922 Madrid, Spain
- Correspondence: ; Tel.: +34-916-219-666
| | - Miguel Brito-Sanfiel
- Department of Endocrinology and Nutrition, Hospital Universitario Puerta de Hierro, Majadahonda, 28222 Madrid, Spain
| | - Teresa Antón-Bravo
- Department of Endocrinology and Nutrition, Hospital Universitario de Móstoles, Móstoles, 28935 Madrid, Spain
| | | | - Jaime Wong-Cruz
- Department of Endocrinology and Nutrition, Hospital Universitario Fundación Alcorcón, Alcorcón, 28922 Madrid, Spain
| | - Manuel A. Gargallo Fernández
- Department of Endocrinology and Nutrition, Fundación Jiménez Díaz, 28040 Madrid, Spain
- Department of Endocrinology and Nutrition, Hospital Universitario Infanta Leonor, 28031 Madrid, Spain
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Bellido V, Martínez J, Calvo F, Villarroel A, Lecumberri E, Moreno J, Morillas C, Rodrigo S, Izarra A, Lecube A. Beyond the Glycaemic Control of Dapagliflozin: Microangiopathy and Non-classical Complications. Diabetes Ther 2022; 13:873-888. [PMID: 35338446 PMCID: PMC9076778 DOI: 10.1007/s13300-022-01237-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/21/2022] [Indexed: 11/23/2022] Open
Abstract
Dapagliflozin is a selective sodium-glucose cotransporter 2 inhibitor (SGLT2i) indicated for the treatment of type 2 diabetes mellitus (T2DM), heart failure (HF) with reduced ejection fraction (EF) and chronic kidney disease (CKD). In monotherapy or as an additive therapy, dapagliflozin aids glycaemic control, is associated with reductions in blood pressure and weight, and promotes a favourable lipid profile. In this review, we address the impact of dapagliflozin on cardiovascular risk factors and common microangiopathic complications such as kidney disease and retinopathy in patients with T2DM. Furthermore, we evaluate its potential beneficial effects on other less frequent complications of diabetes, such as macular oedema, cognitive impairment, non-alcoholic fatty liver disease and respiratory disorders during sleep. Moreover, the underuse of SGLT2i in clinical practice is discussed. Our goal is to help translate this evidence into clinical practice.
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Affiliation(s)
- Virginia Bellido
- Endocrinology and Nutrition Department, Virgen del Rocío University Hospital, Sevilla, Spain
| | | | - Fernando Calvo
- Endocrinology and Nutrition Department, "Lozano Blesa" Clinical Hospital, Zaragoza, Spain
| | | | - Edurne Lecumberri
- Endocrinology and Nutrition Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Juan Moreno
- Medical Department, AstraZeneca Spain, Madrid, Spain
| | - Carlos Morillas
- Endocrinology and Nutrition Department, Dr Peset University Hospital of Valencia, Valencia, Spain
| | | | | | - Albert Lecube
- Research Group On Obesity, Diabetes and Metabolism (ODIM), Institute of Biomedical Research of Lleida (IRBLleida), Endocrinology and Nutrition Department, Arnau de Vilanova University Hospital, Lleida, University of Lleida, Avda. Rovira Roure 80, 25198, Lleida, Spain.
- Biomedical Research Networking Center in Diabetes and Associated Metabolic Disorders (CIBERDEM), Carlos III Health Institute, Madrid, Spain.
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7
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Wilding JPH, Evans M, Fernando K, Gorriz JL, Cebrian A, Diggle J, Hicks D, James J, Newland-Jones P, Ali A, Bain S, Da Porto A, Patel D, Viljoen A, Wheeler DC, Del Prato S. The Place and Value of Sodium-Glucose Cotransporter 2 Inhibitors in the Evolving Treatment Paradigm for Type 2 Diabetes Mellitus: A Narrative Review. Diabetes Ther 2022; 13:847-872. [PMID: 35307801 PMCID: PMC8934539 DOI: 10.1007/s13300-022-01228-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/08/2022] [Indexed: 02/07/2023] Open
Abstract
Over recent years, the expanding evidence base for sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapies has revealed benefits beyond their glucose-lowering efficacy in the treatment of Type 2 diabetes mellitus (T2DM), resulting in their recognition as cardiorenal medicines. While SGLT2is continue to be recommended among the second-line therapies for the treatment of hyperglycaemia, their true value now extends to the prevention of debilitating and costly cardiovascular and renal events for high-risk individuals, with particular benefit shown in reducing major adverse cardiac events and heart failure (HF) and slowing the progression of chronic kidney disease. However, SGLT2i usage is still suboptimal among groups considered to be at greatest risk of cardiorenal complications. The ongoing coronavirus disease 2019 (COVID-19) pandemic has intensified financial pressures on healthcare systems, which may hamper further investment in newer effective medicines. Emerging evidence indicates that glycaemic control should be prioritised for people with T2DM in the era of COVID-19 and practical advice on the use of T2DM medications during periods of acute illness remains important, particularly for healthcare professionals working in primary care who face multiple competing priorities. This article provides the latest update from the Improving Diabetes Steering Committee, including perspectives on the value of SGLT2is as cost-effective therapies within the T2DM treatment paradigm, with particular focus on the latest published evidence relating to the prevention or slowing of cardiorenal complications. The implications for ongoing and future approaches to diabetes care are considered in the light of the continuing coronavirus pandemic, and relevant aspects of international treatment guidelines are highlighted with practical advice on the appropriate use of SGLT2is in commonly occurring T2DM clinical scenarios. The 'SGLT2i Prescribing Tool for T2DM Management', previously published by the Steering Committee, has been updated to reflect the latest evidence and is provided in the Supplementary Materials to help support clinicians delivering T2DM care.
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Affiliation(s)
- John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Clinical Sciences Centre, University Hospital Aintree, Liverpool, UK.
| | - Marc Evans
- University Hospital Llandough, Cardiff, UK
| | | | - Jose Luis Gorriz
- University Hospital Clinic, University of Valencia, Valencia, Spain
| | - Ana Cebrian
- Spanish Diabetes Association, Catholic University of Murcia, Service Murciano de Salud, Cartagena, Murcia, Spain
- Centro de Salud Casco Antiguo Cartagena, Murcia, Spain
- Primary Care Research Group, Biomedical Research Institute of Murcia (IMIB), 30120, Murcia, Spain
| | - Jane Diggle
- College Lane Surgery, Ackworth, West Yorkshire, UK
| | | | - June James
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Amar Ali
- Royal Blackburn Hospital, Lancashire, UK
| | - Stephen Bain
- Swansea University and Diabetes Research Unit, Swansea, UK
| | | | | | - Adie Viljoen
- Cambridge University Hospitals NHS Foundation Trust, Stevenage, UK
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8
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Fadini GP, Del Prato S, Avogaro A, Solini A. Challenges and opportunities in real-world evidence on the renal effects of sodium-glucose cotransporter-2 inhibitors. Diabetes Obes Metab 2022; 24:177-186. [PMID: 34747123 PMCID: PMC9298781 DOI: 10.1111/dom.14599] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/27/2021] [Accepted: 11/04/2021] [Indexed: 12/25/2022]
Abstract
With increasing population aging and prevalence of type 2 diabetes (T2D) worldwide, prevention of diabetic complications remains a major unmet need. While cardiovascular outcomes of diabetes are improving over time, diabetic kidney disease (DKD) still leads to an exceedingly high rate of end-stage kidney disease (ESKD). A game-changing opportunity is offered by treatment with sodium-glucose cotransporter-2 (SGLT2) inhibitors. Randomized controlled trials (RCTs) have indisputably shown that SGLT2 inhibitors reduce the rate of DKD progression, the decline in estimated glomerular filtration rate (eGFR), and the development of ESKD. In parallel, SGLT2 inhibitors improve cardiovascular outcomes, especially the risk of hospitalization for heart failure. Real-world studies (RWSs) have largely confirmed the findings of RCTs in broader populations of subjects with T2D followed under routine care. In the present paper, we review RWSs exploring the renal effects of SGLT2 inhibitors and highlight the most critical challenges that can be encountered in designing and conducting such studies. Channelling bias (confounding by indication), time-lag bias, conditioning on the future, database heterogeneity, linearity of eGFR change over time, and duration of observation are critical issues that may undermine the robustness of RWS findings. We then elaborate on the new opportunities to overcome such limitations by describing the design and objectives of the DARWIN (DApagliflozin Real-World evIdeNce)-Renal study, a new RWS promoted by the Italian Diabetes Society. Fine-tuning of methods for comparative observational research will improve evidence derived from RWSs on the renal effects of SGLT2 inhibitors, aiding the evolving discussion regarding the place of SGLT2 inhibitors in T2D treatment algorithms in different stages of DKD.
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Affiliation(s)
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, Section of Metabolic Diseases and DiabetesUniversity of PisaPisaItaly
| | | | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area PathologyUniversity of PisaPisaItaly
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Caruso I, Giorgino F. SGLT-2 inhibitors as cardio-renal protective agents. Metabolism 2022; 127:154937. [PMID: 34808144 DOI: 10.1016/j.metabol.2021.154937] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 12/19/2022]
Abstract
Despite remarkable advances in diabetes care, patients with type 2 diabetes are still burdened by higher morbidity and mortality than non-diabetic individuals. Atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease represent the most relevant causes of morbidity and mortality and sustain each other in a vicious circle. Cardiovascular diseases are the main cause of death in patients with chronic kidney disease, and, in turn, chronic kidney disease is a significant contributor to the risk of major cardiovascular events and hospitalization for heart failure. Cardiovascular outcome trials with SGLT-2 inhibitors in type 2 diabetes yielded unprecedented results on prevention of worsening heart failure and renal disease progression and mortality, further confirmed by randomized controlled trials in patients with baseline heart failure and chronic kidney disease, with or without diabetes, and observations from the real-world setting. However, the evidence regarding SGLT-2 inhibitors benefit on atherosclerotic cardiovascular events is conflicting. Hence, SGLT-2 inhibitors represent a remarkably valuable weapon in diabetes management, to be used in the context of a multi-targeted treatment strategy to address the many issues of this multifaceted disease.
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Affiliation(s)
- Irene Caruso
- Department of Emergency and Organ Transplantation, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Francesco Giorgino
- Department of Emergency and Organ Transplantation, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy.
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10
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Sun X, Wang G. Renal outcomes with sodium-glucose cotransporters 2 inhibitors. Front Endocrinol (Lausanne) 2022; 13:1063341. [PMID: 36531469 PMCID: PMC9752889 DOI: 10.3389/fendo.2022.1063341] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/08/2022] [Indexed: 12/05/2022] Open
Abstract
Diabetic nephropathy (DN) is one of the most serious complications of diabetes. Therefore, delaying and preventing the progression of DN becomes an important goal in the clinical treatment of type 2 diabetes mellitus. Recent studies confirm that sodium-glucose cotransporters 2 inhibitors (SGLT2is) have been regarded as effective glucose-lowering drugs with renal protective effect. In this review, we summarize in detail the present knowledge of the effects of SGLT2is on renal outcomes by analyzing the experimental data in preclinical study, the effects of SGLT2is on estimated glomerular flitration rates (eGFRs) and urinary albumin-creatinine ratios (UACRs) from clinical trials and observational studies, and renal events (such as renal death or renal failure requiring renal replacement therapy) in some large prospective cardiovaslucar outcomes trials. The underlying mechanisms for renoprotective activity of SGLT2is have been demondtrated in multiple diabetic and nondiabetic animal models including kidney-specific effects and secondary kidney effects related to amelioration in blood glucose and blood pressure. In conclusion, these promising results show that SGLT2is act beneficially in terms of the kidney for diabetic patients.
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11
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Fadini GP, Morales C, Caballero I, González B, Tentolouris N, Consoli A. Efficacy of Dapagliflozin in Southern Europe Across the Spectrum of Characteristics of Type 2 Diabetes: An International Real-World Analysis. Diabetes Metab Syndr Obes 2022; 15:3533-3541. [PMID: 36411790 PMCID: PMC9675331 DOI: 10.2147/dmso.s390075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To extend a prior real-world analysis (DARWIN-T2D) of patients with type 2 diabetes initiating dapagliflozin in Italy, Greece, and Spain by evaluating changes in glycemic and extra-glycemic endpoints after initiation of dapagliflozin. PATIENTS AND METHODS The association among demographic/clinical characteristics and the change in glycemic and extraglycemic effectiveness endpoints during the observation period was assayed using a mixed effects model. RESULTS A total of 1438 (860 males; 59.8%) patients were evaluated; patients were followed for a mean of 5.6 months. At baseline, 93.4% and 61.9% of patients were on concomitant metformin and insulin, respectively. A significant mean decrease in HbA1c from 8.7% to 7.5% was observed. The mixed model used also revealed several associations between different glycemic and laboratory parameters and patient characteristics at baseline; insulin use was significantly associated with lower HbA1c. Patients with BMI ≥30 kg/m2 experienced greater weight loss than those with BMI <30 kg/m2. A consistent glucose-lowering effect of dapagliflozin was seen in all subgroups of patients, including those with stage 2 renal impairment and cardiovascular disease. CONCLUSION The present analysis confirms the efficacy of dapagliflozin in diversified real-world settings with broadly similar effects on HbA1c across countries and baseline characteristics.
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Affiliation(s)
- Gian Paolo Fadini
- Division of Metabolic Diseases, Department of Medicine, University of Padova, Padua, Italy
- Correspondence: Gian Paolo Fadini, Department of Medicine, University of Padova, Via Giustiniani 2, Padova, 35128, Italy, Tel +39 049 8214318, Email
| | - Cristobal Morales
- Hospital Virgen Macarena (Sevilla); Hospital Vithas (Sevilla), Sevilla, Spain
| | - Irene Caballero
- Hospital Virgen Macarena (Sevilla); Hospital Vithas (Sevilla), Sevilla, Spain
| | - Beatriz González
- Hospital Virgen Macarena (Sevilla); Hospital Vithas (Sevilla), Sevilla, Spain
| | - Nikolaos Tentolouris
- Diabetes Centre, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Agostino Consoli
- Department of Medicine and Aging Sciences (DMSI) and Center of Advanced Studies and Technologies (CAST), University of Chieti, Chieti, Italy
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12
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Yang AY, Chen HC. Comparative Assessment of the Long-Term Effectiveness and Safety of Dapagliflozin and Empagliflozin as Add-on Therapy to Hypoglycemic Drugs in Patients with Type 2 Diabetes. J Diabetes Res 2022; 2022:2420857. [PMID: 35656359 PMCID: PMC9152409 DOI: 10.1155/2022/2420857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/25/2022] [Accepted: 05/10/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce blood glucose, blood pressure, and body weight in patients with type 2 diabetes (T2D). However, the comparative long-term effectiveness and safety of SGLT2i among similar drugs, administered at different doses, have not been assessed. In this study, we compared the long-term effectiveness and safety of SGLT2i (dapagliflozin versus empagliflozin) as add-on therapy to hypoglycemic agents in T2D patients. METHODS This study was a single-center, 3-year, retrospective, observational study. For all patients in the study, drugs were evaluated for safety by documenting adverse drug reactions. The primary effectiveness was evaluated as the difference between hemoglobin A1c (HbA1c) values obtained at baseline and those obtained after 36 months of treatment. The proportion of participants with HbA1c levels <7.0% and <6.5% was also analyzed. RESULTS In total, 680 patients were enrolled in this study. Using propensity score matching, 234 patients each from the dapagliflozin and empagliflozin groups were selected based on patient characteristics. After 36 months of treatment, clinical parameters (including HbA1c, fasting plasma glucose, alanine aminotransferase, triglyceride levels, body weight, and systolic blood pressure) decreased significantly in these groups. The changes from the baseline for the physiological values and clinical parameters did not vary among the different dose groups of SGLT2i. The incidence of adverse drug reactions was approximately 7-8%. All patients with observed serious adverse reactions were hospitalized for urinary tract infections. CONCLUSION Our study showed that the long-term continuous use of either dapagliflozin or empagliflozin as add-on therapy to hypoglycemic drugs for T2D patients is synergistically effective for lowering blood glucose, reducing body weight, and stabilizing blood pressure. Additionally, there was no significant difference in efficacy between dapagliflozin and empagliflozin, even with the administration of different doses of these agents.
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Affiliation(s)
- Ai-Yu Yang
- Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Chun Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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13
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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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14
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Lin FJ, Wang CC, Hsu CN, Yang CY, Wang CY, Ou HT. Renoprotective effect of SGLT-2 inhibitors among type 2 diabetes patients with different baseline kidney function: a multi-center study. Cardiovasc Diabetol 2021; 20:203. [PMID: 34620182 PMCID: PMC8499571 DOI: 10.1186/s12933-021-01396-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/01/2021] [Indexed: 01/10/2023] Open
Abstract
Background To assess the effect of sodium glucose cotransporter-2 inhibitors (SGLT-2is) for type 2 diabetes on kidney outcomes stratified by patient baseline estimated glomerular filtration rate (eGFR) levels (i.e., eGFR ≤ 60, 60 < eGFR ≤ 90, and eGFR > 90 mL/min/1.73 m2). Methods Patients from three large healthcare delivery systems in Taiwan who had initiated SGLT-2is or other glucose-lowering drugs (oGLDs) between May 2016 and December 2017 were included. Main outcomes were the times to 30%, 40%, and 50% eGFR reduction after treatment initiation. One-to-one propensity score matching in the overall study cohort and in each eGFR subgroup between SGLT-2i and oGLD users was applied to ensure between-group comparability in baseline characteristics. Results There were 13,666 matched pairs of SGLT-2is and oGLD users in the overall cohort. While a sustained eGFR decline was revealed in oGLD-treated patients (mean values [standard errors] from 85.61 [0.43] to 82.49 [0.44] mL/min/1.73 m2 during the 12 months after treatment initiation), the mean eGFR values of SGLT-2i users decreased in the first 3 months (85.68 [0.37] to 79.71 [0.41] mL/min/1.73 m2) but then improved and sustained until the end of follow-up. There were 2300, 5705, and 5509 matched SGLT-2i and oGLD users in the eGFR ≤ 60, 60 < eGFR ≤ 90, and eGFR > 90 subgroups, respectively. Using SGLT-2is versus oGLDs was significantly associated with slower eGFR declines; hazard ratios (HRs) were 0.51 (95% CI 0.37–0.69), 0.51 (0.37–0.70), and 0.47 (0.31–0.71) for 40% eGFR reduction in the eGFR ≤ 60, 60 < eGFR ≤ 90, and eGFR > 90 subgroups, respectively. The renoprotective effect of SGLT-2is versus oGLDs was confirmed in the outcomes of 30% and 50% eGFR reduction across the three eGFR subgroups. Conclusions This study supports the renoprotective benefit of real-world SGLT-2i use irrespective of patient baseline kidney function. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01396-2.
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Affiliation(s)
- Fang-Ju Lin
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Chuan Wang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chen-Yi Yang
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Yuan Wang
- College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Huang-Tz Ou
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Department of Pharmacy, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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15
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Morieri ML, Vitturi N, Avogaro A, Targher G, Fadini GP. Prevalence of hepatic steatosis in patients with type 2 diabetes and response to glucose-lowering treatments. A multicenter retrospective study in Italian specialist care. J Endocrinol Invest 2021; 44:1879-1889. [PMID: 33432553 DOI: 10.1007/s40618-021-01501-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/05/2021] [Indexed: 12/28/2022]
Abstract
AIM Type 2 diabetes (T2D) is a risk factor for metabolic dysfunction-associated fatty liver disease (MAFLD), which is becoming the commonest cause of chronic liver disease worldwide. We estimated MAFLD prevalence among patients with T2D using the hepatic steatosis index (HSI) and validated it against liver ultrasound. We also examined whether glucose-lowering medications (GLM) beneficially affected HSI. METHODS We collected data from 46 diabetes clinics (n = 281,381 T2D patients), extracted data to calculate HSI and validated it against ultrasound-detected hepatic steatosis. We then examined changes in HSI among patients with a follow-up visit within 1 year after initiating newer GLMs. RESULTS MAFLD (defined by HSI > 36, i.e., a high probability of steatosis) was present in 76.3% of the 78,895 included patients, while only 2.7% had HSI < 30 (low probability of steatosis). After age- and sex-adjusting, higher HSI was associated with higher prevalence of chronic kidney disease (odds ratio 1.35; 95%CI 1.22-1.51) and macroangiopathy (odds ratio 1.18; 95%CI 1.07-1.30). Among 2,179 subjects in the validation cohort, the prevalence of MAFLD was 67.8% and was greater in those with high HSI. Performance of HSI for ultrasound-detected MAFLD was moderate (AUROC 0.70), yet steatosis prevalence was > threefold higher among subjects with HSI > 36 than among those with HSI < 30. Notably, HSI declined significantly ~ 6 months after initiation of dapagliflozin or incretin-based therapies, but not gliclazide. CONCLUSION About three quarters of patients with T2D have HSI values suggestive of MAFLD, a condition associated with macroangiopathy and nephropathy. Treatment with dapagliflozin or incretin therapies might improve MAFLD in T2D.
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Affiliation(s)
- M L Morieri
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - N Vitturi
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - A Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - G Targher
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Piazzale A. Stefani 1, 37126, Verona, Italy
| | - G P Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
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16
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Real J, Vlacho B, Ortega E, Vallés JA, Mata-Cases M, Castelblanco E, Wittbrodt ET, Fenici P, Kosiborod M, Mauricio D, Franch-Nadal J. Cardiovascular and mortality benefits of sodium-glucose co-transporter-2 inhibitors in patients with type 2 diabetes mellitus: CVD-Real Catalonia. Cardiovasc Diabetol 2021; 20:139. [PMID: 34243779 PMCID: PMC8272340 DOI: 10.1186/s12933-021-01323-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023] Open
Abstract
Background Evidence from prospective cardiovascular (CV) outcome trials in type 2 diabetes (T2DM) patients supports the use of sodium–glucose co-transporter-2 inhibitors (SGLT2i) to reduce the risk of CV events. In this study, we compared the risk of several CV outcomes between new users of SGLT2i and other glucose-lowering drugs (oGLDs) in Catalonia, Spain. Methods CVD-REAL Catalonia was a retrospective cohort study using real-world data routinely collected between 2013 and 2016. The cohorts of new users of SGLT2i and oGLDs were matched by propensity score on a 1:1 ratio. We compared the incidence rates and hazard ratio (HR) for all-cause death, hospitalization for heart failure, chronic kidney disease, and modified major adverse CV event (MACE; all-cause mortality, myocardial infarction, or stroke). Results After propensity score matching, 12,917 new users were included in each group. About 27% of users had a previous history of CV disease. In the SGLT2i group, the exposure time was 60% for dapagliflozin, 26% for empagliflozin and 14% for canagliflozin. The use of SGLT2i was associated with a lower risk of heart failure (HR: 0.59; 95% confidence interval [CI] 0.47–0.74; p < 0.001), all-cause death (HR = 0.41; 95% CI 0.31–0.54; p < 0.001), all-cause death or heart failure (HR = 0.55; 95% CI 0.47–0.63; p < 0.001), modified MACE (HR = 0.62; 95% CI 0.52–0.74; p < 0.001), and chronic kidney disease (HR = 0.66; 95% CI 0.54–0.80; p < 0.001). Conclusions In this large, retrospective observational study of patients with T2DM from a Catalonia, initiation of SGLT-2i was associated with lower risk of mortality, as well as heart failure and CKD. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01323-5.
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Affiliation(s)
- Jordi Real
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Bogdan Vlacho
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Emilio Ortega
- Department of Endocrinology and Nutrition, Institut d'Investigacions Biomèdiques August Pi i Suñer, Hospital Clinic, Barcelona, Spain.,CIBER of Physiopathology of Obesity and Nutrition (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Joan Antoni Vallés
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.,Drug Area, Gerència d'Atenció Primaria, Institut Català de la Salut, Barcelona, Spain
| | - Manel Mata-Cases
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain.,Primary Health Care Center La Mina, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Sant Adrià de Besòs, Spain
| | - Esmeralda Castelblanco
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain.,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | | | - Peter Fenici
- Cardiovascular Renal Metabolisms, BioPharmaceuticals Global Medical, AstraZeneca, Cambridge, UK
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA
| | - Dídac Mauricio
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain. .,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain. .,Department of Endocrinology and Nutrition, Hospital Universitari de la Santa Creu i Sant Pau, Autonomous Universtity of Barcelona, Sant Quintí, 89, 08041, Barcelona, Spain. .,Departament of Medicine, University of Vic-Central University of Catalonia, Vic, Barcelona, Spain.
| | - Josep Franch-Nadal
- DAP‑Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain. .,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain. .,Primary Health Care Center Raval Sud, Gerència d'Atenció Primaria, Institut Català de la Salut, Av. Drassanes, 17-21, 08001, Barcelona, Spain.
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Rossing P, Persson F. What Have We Learned so Far From the Use of Sodium-Glucose Cotransporter 2 Inhibitors in Clinical Practice? Adv Chronic Kidney Dis 2021; 28:290-297. [PMID: 34922685 DOI: 10.1053/j.ackd.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/16/2021] [Accepted: 06/01/2021] [Indexed: 11/11/2022]
Abstract
Since the introduction of sodium-glucose cotransporter 2 (SGLT2) inhibitors, the aim of this therapy has expanded from being solely a glucose-lowering treatment into also being organ protective even in people without diabetes. In this review, we present this evolution of the treatment principle, from early studies over randomized controlled trials. We discuss available real-world evidence and summarize a number of recent post hoc analyses from the randomized controlled trials with kidney end points. As the use of sodium-glucose cotransporter 2 inhibitors becomes more widespread, new questions arise regarding initiation and follow-up, which we try to answer by providing the currently available data. For translation of study results to global effects, implementation becomes important. As is often the case, this does not happen without barriers, which must be addressed and handled. Finally, future studies and populations are discussed because it may well be that sodium-glucose cotransporter 2 inhibition are expanding into further areas.
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18
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A Bioinformatics Investigation into the Pharmacological Mechanisms of Sodium-Glucose Co-transporter 2 Inhibitors in Diabetes Mellitus and Heart Failure Based on Network Pharmacology. Cardiovasc Drugs Ther 2021; 36:713-726. [PMID: 34028657 PMCID: PMC9270285 DOI: 10.1007/s10557-021-07186-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Diabetes mellitus (DM) is a major risk factor for the development of heart failure (HF). Sodium-glucose co-transporter 2 (SGLT2) inhibitors have demonstrated consistent benefits in the reduction of hospitalization for HF in patients with DM. However, the pharmacological mechanism is not clear. To investigate the mechanisms of SGLT2 inhibitors in DM with HF, we performed target prediction and network analysis by a network pharmacology method. METHODS We selected targets of SGLT2 inhibitors and DM status with HF from databases and studies. The "Drug-Target" and "Drug-Target-Disease" networks were constructed using Cytoscape. Then the protein-protein interaction (PPI) was analyzed using the STRING database. Gene Ontology (GO) biological functions and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were performed to investigate using the Bioconductor tool for analysis. RESULTS There were 125 effective targets between SGLT2 inhibitors and DM status with HF. Through further screening, 33 core targets were obtained, including SRC, MAPK1, NARS, MAPK3 and EGFR. It was predicted that the Rap1 signaling pathway, MAPK signaling pathway, EGFR tyrosine kinase inhibitor resistance, AGE-RAGE signaling pathway in diabetic complications and other signaling pathways were involved in the treatment of DM with HF by SGLT2 inhibitors. CONCLUSION Our study elucidated the possible mechanisms of SGLT2 inhibitors from a systemic and holistic perspective based on pharmacological networks. The key targets and pathways will provide new insights for further research on the pharmacological mechanism of SGLT2 inhibitors in the treatment of DM with HF.
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Kobayashi K, Toyoda M, Hatori N, Saito N, Kanaoka T, Sakai H, Furuki T, Umezono T, Ito S, Suzuki D, Takeda H, Minagawa F, Degawa H, Yamamoto H, Machimura H, Chin K, Hishiki T, Takihata M, Aoyama K, Umezawa S, Minamisawa K, Aoyama T, Hamada Y, Suzuki Y, Hayashi M, Hatori Y, Sato K, Miyakawa M, Tamura K, Kanamori A. Retrospective Analysis of the Renoprotective Effects of Long-Term Use of Six Types of Sodium-Glucose Cotransporter 2 Inhibitors in Japanese Patients with Type 2 Diabetes Mellitus and Chronic Kidney Disease. Diabetes Technol Ther 2021; 23:110-119. [PMID: 32721227 DOI: 10.1089/dia.2020.0165] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Aim: Sodium-glucose cotransporter 2 inhibitors (SGLT2is) provide renal protection in patients with type 2 diabetes mellitus (T2DM). The aim of this study was to elucidate the renal effects of long-term use of six types of SGLT2is in Japanese patients with T2DM and chronic kidney disease (CKD). Materials and Methods: The Kanagawa Physicians Association maintains a registry of patients who visit their 31 clinics. We retrieved clinical data of patients with T2DM and CKD who were prescribed with SGLT2is for >1 year. Results: A total of 763 patients with a median treatment duration of 33 months were included. The logarithmic value of urine albumin-creatinine ratio (LNACR) decreased significantly from 1.60 ± 0.65 to 1.51 ± 0.67. The multiple linear regression analysis revealed that the LNACR at the initiation of treatment, change in (Δ) diastolic blood pressure, and Δ hemoglobin A1c were independently correlated with ΔLNACR (P < 0.001). The decrease in the LNACR was significantly smaller in the patients with estimated glomerular filtration rate (eGFR) [mL/(min ·1.73 m2)] of <60 (P < 0.05). The eGFR decreased from 77.4 ± 22.3 to 72.7 ± 22.5 mL/(min ·1.73 m2) (P < 0.001). The multiple linear regression analysis showed that the LNACR at the initiation of treatment, Δbody weight at the previous survey, ΔeGFR at the previous survey, and the eGFR at the initiation of treatment correlated independently with ΔeGFR during the maintenance period (P < 0.001). Greater changes in the eGFR during the maintenance period were observed in the patients with macroalbuminuria or eGFR of <60 (P < 0.01). Conclusions: The study confirmed that the long-term use of six types of SGLT2i improved the albumin-creatinine ratio (ACR), although the eGFR gradually decreased during the treatment. The change in the ACR was significantly smaller in the patients with eGFR of <60 mL/(min ·1.73 m2) than in those with eGFR of >60 mL/(min ·1.73 m2). However, this was a retrospective observational study; further studies are needed to formulate final conclusions.
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Affiliation(s)
- Kazuo Kobayashi
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masao Toyoda
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Nobuo Hatori
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Nobumichi Saito
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Tomohiko Kanaoka
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hiroyuki Sakai
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Takayuki Furuki
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Tomoya Umezono
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Shun Ito
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Daisuke Suzuki
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Hiroshi Takeda
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Fuyuki Minagawa
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Hisakazu Degawa
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Hareaki Yamamoto
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Hideo Machimura
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Keiichi Chin
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Toshimasa Hishiki
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Masahiro Takihata
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Kouta Aoyama
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Shinichi Umezawa
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Kohsuke Minamisawa
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Togo Aoyama
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Yoshiro Hamada
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Yoshiro Suzuki
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Masahiro Hayashi
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Yutaka Hatori
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Kazuyoshi Sato
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Masaaki Miyakawa
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akira Kanamori
- Committee of Hypertension and Kidney Disease, Kanagawa Physicians Association, Yokohama, Japan
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20
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Hussein N, Abdelrahman F, Khedr A, Aref H, Halawa MR, ELSharkawy M. Value of Sodium-Glucose Co-Transporter 2 Inhibitor Versus Traditional Medication in Microalbuminuric Diabetic Patients. Curr Diabetes Rev 2021; 17:e101120187809. [PMID: 33176660 DOI: 10.2174/1573399816999201110194413] [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: 07/19/2020] [Revised: 09/21/2020] [Accepted: 09/30/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Sodium glucose co-transporter 2 inhibitor (SGLT2i) is a new arment in the prevention and treatment of diabetic kidney disease with a potential effect on reducing and preventing Chronic Kidney Disease (CKD) progression. OBJECTIVE To evaluate the effect of SGLT2 inhibitor in comparison to traditional medication in diabetic patients with microalbuminuria. METHODS A total of 60 diabetic patients with microalbuminuria were divided into group I, where 30 patients were treated by traditional medications (RAAS blockers) and group II where 30 patients were treated by Dapagliflozin added to the traditional medications. All patients were followed up for 6 months and their Urine Albumin/Creatinine Ratio (UACR) and eGFR changes were monitered. RESULTS UACR significantly declined after 6 months of treatment in group II with a p-value <0.001. There were no significant eGFR changes between both groups. Systolic blood pressure decreases in both groups, but the decrease was highly significant in group II (pvalue<0.001). Diastolic blood pressure decreases significantly in both groups (p-value<0.001). Also, bodyweight reduced significantly in group II with a p-value<0.001. CONCLUSION Dapagliflozin, when added to traditional medications (RAAS Blockers), leads to a significant reduction in microalbuminuria with no significant eGFR changes.
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Affiliation(s)
- Nahla Hussein
- Department of Internal Medicine and Nephrology, Ain Shams University, Cairo, Egypt
| | - Fatma Abdelrahman
- Department of Internal Medicine and Nephrology, Ain Shams University, Cairo, Egypt
| | - Abdelrahman Khedr
- Department of Internal Medicine and Nephrology, Ain Shams University, Cairo, Egypt
| | - Hayam Aref
- Department of Internal Medicine and Nephrology, Ain Shams University, Cairo, Egypt
| | - Mohamed Reda Halawa
- Department of Internal Medicine and Endocrinology, Ain Shams University, Cairo, Egypt
| | - Magdy ELSharkawy
- Department of Internal Medicine and Nephrology, Ain Shams University, Cairo, Egypt
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21
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Roy A, Maiti A, Sinha A, Baidya A, Basu AK, Sarkar D, Sanyal D, Biswas D, Maisnam I, Pandit K, Raychaudhuri M, Sengupta N, Chakraborty PP, Mukhopadhyay P, Raychaudhuri P, Sahana PK, Chatterjee P, Bhattacharjee R, Dasgupta R, Saraogi RK, Pal SK, Mukhopadhyay S, Mukhopadhyay S, Goswami S, Chowdhury S, Ghosh S. Kidney Disease in Type 2 Diabetes Mellitus and Benefits of Sodium-Glucose Cotransporter 2 Inhibitors: A Consensus Statement. Diabetes Ther 2020; 11:2791-2827. [PMID: 33025397 PMCID: PMC7644753 DOI: 10.1007/s13300-020-00921-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Indexed: 12/28/2022] Open
Abstract
Diabetic kidney disease (DKD) occurs in approximately 20-40% of patients with type 2 diabetes mellitus. Patients with DKD have a higher risk of cardiovascular and all-cause mortality. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and antihyperglycemic drugs form the mainstay of DKD management and aim to restrict progression to more severe stages of DKD. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) control hyperglycemia by blocking renal glucose reabsorption in addition to preventing inflammation, thereby improving endothelial function and reducing oxidative stress; consequently, this class of prescription medicines is emerging as an important addition to the therapeutic armamentarium. The EMPA-REG OUTCOME, DECLARE TIMI 58, and CANVAS trials demonstrated the renoprotective effects of SGLT2i, such as restricting decline in glomerular filtration rate, in the progression of albuminuria, and in death due to renal causes. The renoprotection provided by SGLT2i was further confirmed in the CREDENCE study, which showed a 30% reduction in progression of chronic kidney disease, and in the DELIGHT study, which demonstrated a reduction in albuminuria with dapagliflozin compared with placebo (- 21.0%, confidence interval [CI] - 34.1 to - 5.2, p = 0.011). Furthermore, a meta-analysis demonstrated a reduced risk of dialysis, transplantation, or death due to kidney disease (relative risk 0.67; 95% CI 0.52-0.86; p = 0.0019) and a 45% risk reduction in worsening of renal function, end-stage renal disease, or renal death (hazard ratio 0.55, CI 0.48-0.64, p < 0.0001) with SGLT2i, irrespective of baseline estimated glomerular filtration rate. Thus, there is emerging evidence that SGLT2i may be used to curb the mortality and improve the quality of life in patients with DKD. However, clinicians need to effectively select candidates for SGLT2i therapy. In this consensus statement, we have qualitatively synthesized evidence demonstrating the renal effects of SGLT2i and proposed recommendations for optimal use of SGLT2i to effectively manage and delay progression of DKD.
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Affiliation(s)
- Ajitesh Roy
- Department of Endocrinology, Ramakrishna Mission Seva Pratishthan, Calcutta, West Bengal, India
| | - Animesh Maiti
- Department of Endocrinology and Metabolism, Medical College and Hospital, Calcutta, West Bengal, India
| | - Anirban Sinha
- Department of Endocrinology and Metabolism, Medical College and Hospital, Calcutta, West Bengal, India
| | - Arjun Baidya
- Department of Endocrinology and Metabolism, Nil Ratan Sircar Medical College and Hospital, Calcutta, West Bengal, India
| | - Asish Kumar Basu
- Department of Endocrinology and Metabolism, Medical College and Hospital, Calcutta, West Bengal, India
| | | | - Debmalya Sanyal
- Department of Endocrinology, KPC Medical College and Hospital, Calcutta, West Bengal, India
| | - Dibakar Biswas
- Department of Endocrinology, IPGMER and SSKM Hospital, Calcutta, West Bengal, India
| | - Indira Maisnam
- Department of Endocrinology, RG Kar Medical College and Hospital, Calcutta, West Bengal, India
| | - Kaushik Pandit
- Department of Endocrinology, Belle Vue Clinic, Calcutta, West Bengal, India
| | - Moutusi Raychaudhuri
- Department of Endocrinology, Institute of Child Health, Calcutta, West Bengal, India
| | - Nilanjan Sengupta
- Department of Endocrinology and Metabolism, Nil Ratan Sircar Medical College and Hospital, Calcutta, West Bengal, India
| | - Partha Pratim Chakraborty
- Department of Endocrinology and Metabolism, Medical College and Hospital, Calcutta, West Bengal, India
| | - Pradip Mukhopadhyay
- Department of Endocrinology, IPGMER and SSKM Hospital, Calcutta, West Bengal, India
| | | | - Pranab Kumar Sahana
- Department of Endocrinology and Metabolism, Nil Ratan Sircar Medical College and Hospital, Calcutta, West Bengal, India
| | | | - Rana Bhattacharjee
- Department of Endocrinology, IPGMER and SSKM Hospital, Calcutta, West Bengal, India
| | - Ranen Dasgupta
- Rittik Clinic & Laboratory, Calcutta, West Bengal, India
| | | | - Salil Kumar Pal
- Department of Medicine, Calcutta National Medical College, Calcutta, West Bengal, India
| | | | | | - Soumik Goswami
- Department of Endocrinology and Metabolism, Nil Ratan Sircar Medical College and Hospital, Calcutta, West Bengal, India
| | - Subhankar Chowdhury
- Department of Endocrinology, IPGMER and SSKM Hospital, Calcutta, West Bengal, India
| | - Sujoy Ghosh
- Department of Endocrinology, IPGMER and SSKM Hospital, Calcutta, West Bengal, India.
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22
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Giorgino F, Vora J, Fenici P, Solini A. Renoprotection with SGLT2 inhibitors in type 2 diabetes over a spectrum of cardiovascular and renal risk. Cardiovasc Diabetol 2020; 19:196. [PMID: 33222693 PMCID: PMC7680601 DOI: 10.1186/s12933-020-01163-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
Approximately half of all patients with type 2 diabetes (T2D) develop a certain degree of renal impairment. In many of them, chronic kidney disease (CKD) progresses over time, eventually leading to end-stage kidney disease (ESKD) requiring dialysis and conveying a substantially increased risk of cardiovascular morbidity and mortality. Even with widespread use of renin-angiotensin system blockers and tight glycemic control, a substantial residual risk of nephropathy progression remains. Recent cardiovascular outcomes trials investigating sodium-glucose cotransporter 2 (SGLT2) inhibitors have suggested that these therapies have renoprotective effects distinct from their glucose-lowering action, including the potential to reduce the rates of ESKD and acute kidney injury. Although patients in most cardiovascular outcomes trials had higher prevalence of existing cardiovascular disease compared with those normally seen in clinical practice, the proportion of patients with renal impairment was similar to that observed in a real-world context. Patient cardiovascular risk profiles did not relevantly impact the renoprotective benefits observed in these studies. Benefits were observed in patients across a spectrum of renal risk, but were evident also in those without renal damage, suggesting a role for SGLT2 inhibition in the prevention of CKD in people with T2D. In addition, recent studies such as CREDENCE and DAPA-CKD offer a greater insight into the renoprotective effects of SGLT2 inhibitors in patients with moderate-to-severe CKD. This review outlines the evidence that SGLT2 inhibitors may prevent the development of CKD and prevent and delay the worsening of CKD in people with T2D at different levels of renal risk.
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Affiliation(s)
- Francesco Giorgino
- Department of Emergency and Organ Transplantation, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Policlinico, Piazza Giulio Cesare, 11, 70124, Bari, Italy.
| | - Jiten Vora
- Diabetes and Endocrinology, University of Liverpool, Liverpool, UK
| | | | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
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23
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Zhang X, Zhong Z, Li Y, Li W. Long-term renal outcomes associated with sodium glucose cotransporter 2 inhibitors in patients with type 2 diabetes mellitus: A systematic review and meta-analysis. Diabetes Metab Res Rev 2020; 36:e3303. [PMID: 32134558 DOI: 10.1002/dmrr.3303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 10/08/2019] [Accepted: 02/18/2020] [Indexed: 12/13/2022]
Abstract
AIMS The long-term impact of sodium glucose cotransporter 2 (SGLT2) inhibitors on renal functions remains undefined. This study was undertaken to investigate the renal outcomes associated with SGLT2 inhibitors in patients with type 2 diabetes (T2DM) in the long term. METHODS A systematic literature search of PubMed and ClinicalTrials.gov was conducted. Randomized controlled trials which reported renal outcomes at the study endpoint in patients with T2DM receiving treatments of SGLT2 inhibitors were included. Renal adverse events were determined using prespecified lists from the Medical Dictionary for Regulatory Activities or laboratory values. Odds ratio with 95% confidence interval (CI) was used for assessment of dichotomous data. The mean difference or standardized mean difference with 95% CI was used for assessment of continuous data. Random effects models were adopted to measure the pooled outcomes. RESULTS Thirty-nine studies involving 35 trials were identified. Compared with placebo or other anti-diabetic medications, SGLT2 inhibitors were associated with significant lower incidence of composite renal outcome and acute renal failure or injury in patients with T2DM. The risk of progression of albuminuria also appeared to be decreased. No significant changes of estimated glomerular filtration rate levels or urine albumin-creatinine ratios were found in patients receiving SGLT2 inhibitors. CONCLUSIONS Overall renal safety and beneficial effects are indicated for SGLT2 inhibitors. Further confirmative data from large trials and real-world studies are needed.
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Affiliation(s)
- Xiaodan Zhang
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhen Zhong
- Department of Endocrinology, The First People's Hospital of Nankang District, Ganzhou, China
| | - Yanli Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wangen Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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24
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Sridhar VS, Rahman HU, Cherney DZI. What have we learned about renal protection from the cardiovascular outcome trials and observational analyses with SGLT2 inhibitors? Diabetes Obes Metab 2020; 22 Suppl 1:55-68. [PMID: 32267075 DOI: 10.1111/dom.13965] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 12/21/2022]
Abstract
Over the past 5 years, sodium-glucose cotransport 2 (SGLT2) inhibitors have been increasingly regarded as glycaemic agents with cardiovascular (CV) and renal protective effects. The CV benefits of SGLT2 inhibitors have been well established in patients with type 2 diabetes (T2D) and a range of CV comorbidities at baseline. Subsequently, the renal benefits of SGLT2 inhibitors were established in the CREDENCE trial, a dedicated renal outcome trial where canagliflozin reduced the primary composite renal outcome by 30%. In light of these trials, clinical practice guidelines have rapidly evolved, recommending the use of SGLT2 inhibitors as renal and cardioprotective agents in appropriate patient populations. Accordingly, it is important to have an in-depth understanding of the evidence underlying the use of SGLT2 inhibitors in patients with T2D based on published clinical trials and real-world evidence (RWE) studies, as well as information related to potential safety concerns. To accomplish this, we reviewed the evidence for renal protection and safety with SGLT2 inhibitors in the EMPA-REG OUTCOME, CANVAS Program and DECLARE-TIMI 58 CV safety trials, and in the growing body of evidence emerging from real-world studies. This body of work has shown that SGLT2 inhibitors reduce the risk of surrogate renal endpoints such as albuminuria and mitigate the risk of hard renal endpoints including doubling of serum creatinine and end-stage kidney disease in patients with T2D.
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Affiliation(s)
- Vikas S Sridhar
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Habib U Rahman
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
- Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology and Department of Pharmacology & Toxicology, University of Toronto, Toronto, Ontario, Canada
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25
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Fadini GP, Li Volsi P, Devangelio E, Poli M, Cazzetta G, Felace G, Avogaro A. Predictors of early discontinuation of dapagliflozin versus other glucose-lowering medications: a retrospective multicenter real-world study. J Endocrinol Invest 2020; 43:329-336. [PMID: 31515744 DOI: 10.1007/s40618-019-01110-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS In routine clinical practice, early discontinuation of newly initiated glucose-lowering medications (GLM) is relatively common. We herein evaluated if the clinical characteristics associated with early discontinuation of dapagliflozin were different from those associated with early discontinuation of other GLM. METHODS The DARWIN-T2D was a multicenter retrospective study conducted at diabetes specialist outpatient clinics in Italy. We included 2484 patients who were initiated on dapagliflozin in 2015-2016 and 14,801 patients who were initiated on other GLM (DPP-4 inhibitors, GLP-1 receptor agonists, or gliclazide) in the same period. After excluding patients who had not (yet) returned to follow-up, we compared the characteristics of patients who persisted on drug versus those who were no longer on drug at the first available follow-up after at least 3 months. RESULTS As compared to those who persisted on drug, patients who discontinued dapagliflozin (51.7%) were more often female, had higher baseline fasting plasma glucose (FPG), HbA1c, and eGFR, and less common use of metformin. Upon multiple regression, higher HbA1c, higher eGFR, and lower metformin use remained independently associated with early discontinuation. Among patients who had been initiated on other GLM, 41.7% discontinued. Variables independently associated with discontinuation were older age, longer diabetes duration, higher HbA1c, eGFR, and albumin excretion, more common use of insulin and less metformin. CONCLUSION In routine clinical practice, all variables associated with dapagliflozin discontinuation were also associated with discontinuation of other GLM. Thus, despite a distinctive mechanism of action and a peculiar tolerability profile, no specific predictor of dapagliflozin discontinuation was detected.
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Affiliation(s)
- G P Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
| | - P Li Volsi
- Ospedale di Pordenone - Azienda per l'Assistenza Sanitaria n.5, Friuli Occidentale, 33170, Pordenone, Italy
| | - E Devangelio
- Presidio Territoriale di Assistenza-Distretto Socio Sanitario di Massafra - Azienda Sanitaria Locale di Taranto, 74016, Massafra, Italy
| | - M Poli
- Ospedale Girolamo Fracastoro di San Bonifacio - Azienda ULSS n.9 Scaligera, 37047, San Bonifacio, Italy
| | - G Cazzetta
- Distretto Socio Sanitario Gagliano del Capo, sede Tricase - Azienda Sanitaria Locale di Lecce, 73039, Tricase, Italy
| | - G Felace
- Ospedale di Spilimbergo - Azienda per l'Assistenza Sanitaria n.5, Friuli Occidentale, 33170, Pordenone, Italy
| | - A Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
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Bonora BM, Avogaro A, Fadini GP. Extraglycemic Effects of SGLT2 Inhibitors: A Review of the Evidence. Diabetes Metab Syndr Obes 2020; 13:161-174. [PMID: 32021362 PMCID: PMC6982447 DOI: 10.2147/dmso.s233538] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 12/24/2019] [Indexed: 12/13/2022] Open
Abstract
Patients with type 2 diabetes (T2D) are often overweight/obese and affected by arterial hypertension, dyslipidaemia, and have high serum levels of uric acid. Moreover, T2D patient have a higher risk of developing cardiovascular or renal complications, which are leading causes of morbidity and mortality in this population. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a new class of glucose-lowering medications that block the reabsorption of glucose in the kidney, thereby increasing urinary glucose excretion, and lowering blood glucose levels. The beneficial effects of SGLT2 inhibition extend beyond glycaemic control, and include improvement in blood pressure, body weight, uric acid concentrations, liver steatosis, oxidative stress, and inflammation. In dedicated cardiovascular outcome trials, SGLT2i treatment was associated with a significant reduction in the rate of cardiovascular events and renal endpoints. In this review, we summarize the evidence for extra-glycemic effects of SGLT2i and the potential mechanisms driving cardiorenal protection exerted by this class of medications.
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Affiliation(s)
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova35128, Italy
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27
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Heerspink HJL, Karasik A, Thuresson M, Melzer-Cohen C, Chodick G, Khunti K, Wilding JPH, Garcia Rodriguez LA, Cea-Soriano L, Kohsaka S, Nicolucci A, Lucisano G, Lin FJ, Wang CY, Wittbrodt E, Fenici P, Kosiborod M. Kidney outcomes associated with use of SGLT2 inhibitors in real-world clinical practice (CVD-REAL 3): a multinational observational cohort study. Lancet Diabetes Endocrinol 2020; 8:27-35. [PMID: 31862149 DOI: 10.1016/s2213-8587(19)30384-5] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/13/2019] [Accepted: 11/13/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Cardiovascular and kidney outcome trials have shown that sodium-glucose co-transporter-2 (SGLT2) inhibitors slow progression of chronic kidney disease in patients with type 2 diabetes with or without chronic kidney disease. The aim of this study was to assess whether these benefits extend to patients with type 2 diabetes treated in routine clinical practice. METHODS CVD-REAL 3 was a multinational observational cohort study in which new users of SGLT2 inhibitors and other glucose-lowering drugs with measurements of estimated glomerular filtration rate (eGFR) before and after (within 180 days) initiation were identified via claims, medical records, and national registries in Israel, Italy, Japan, Taiwan, and the UK. Propensity scores for SGLT2 inhibitor initiation were developed in each country, with 1:1 matching with initiators of other glucose-lowering drugs. Propensity score included (in addition to other clinical and demographic variables) baseline eGFR and eGFR slope before SGLT2 inhibitor or other glucose-lowering drug initiation. The main outcome measure was rate of eGFR decline (slope) calculated with a linear mixed regression model. Differences in eGFR slope between SGLT2 inhibitors and other glucose-lowering drugs were calculated and pooled. We also assessed a composite outcome of 50% eGFR decline or end-stage kidney disease. FINDINGS After propensity matching, there were 35 561 episodes of treatment initiation in each group, from 65 231 individual patients. Dapagliflozin, empagliflozin, canagliflozin, ipragliflozin, tofogliflozin, and luseogliflozin accounted for 57·9%, 34·1%, 5·7%, 1·4%, 0·5%, and 0·4% of SGLT2 inhibitor initiation episodes, respectively. At baseline, 29 363 (41·3%) of 71 122 initiations were in women, mean age was 61·3 years, mean HbA1c was 72 mmol/mol (8·71%), and mean eGFR was 90·7 mL/min per 1·73 m2. During follow-up, SGLT2 inhibitor initiation was associated with reduced eGFR decline (difference in slope for SGLT2 inhibitors vs other glucose-lowering drugs 1·53 mL/min per 1·73 m2 per year, 95% CI 1·34-1·72, p<0·0001). During a mean follow-up of 14·9 months, 351 composite kidney outcomes occurred: 114 (3·0 events per 10 000 patient-years) among initiators of SGLT2 inhibitors and 237 (6·3 events per 10 000 patient-years) among initiators of other glucose-lowering drugs (hazard ratio 0·49, 95% CI 0·35-0·67; p<0·0001). These findings were consistent across countries (pheterogeneity 0·10) and prespecified subgroups. INTERPRETATION In this large, international, real-world study of patients with type 2 diabetes, initiation of SGLT2 inhibitor therapy was associated with a slower rate of kidney function decline and lower risk of major kidney events compared with initiation of other glucose-lowering drugs. These data suggest that the benefits of SGLT2 inhibitors on kidney function identified in clinical trials seem to be largely generalisable to clinical practice. FUNDING AstraZeneca.
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Affiliation(s)
- Hiddo J L Heerspink
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Groningen, Netherlands.
| | - Avraham Karasik
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel; Tel Aviv University, Tel Aviv, Israel
| | | | - Cheli Melzer-Cohen
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Gabriel Chodick
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel; Tel Aviv University, Tel Aviv, Israel
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - John P H Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | | | - Lucia Cea-Soriano
- Centro Español de Investigación Farmacoepidemiológica, Madrid, Spain; Department of Public Health and Maternal and Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Antonio Nicolucci
- Clinical Epidemiology Department, CORESEARCH, Centre for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Giuseppe Lucisano
- Clinical Epidemiology Department, CORESEARCH, Centre for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Fang-Ju Lin
- National Taiwan University, Taipei, Taiwan; National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Yuan Wang
- National Taiwan University, Taipei, Taiwan; National Taiwan University Hospital, Taipei, Taiwan
| | | | | | - Mikhail Kosiborod
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA
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Morieri ML, Rigato M, Frison V, Simioni N, D'Ambrosio M, Tadiotto F, Paccagnella A, Lapolla A, Avogaro A, Fadini GP. Fixed versus flexible combination of GLP-1 receptor agonists with basal insulin in type 2 diabetes: A retrospective multicentre comparative effectiveness study. Diabetes Obes Metab 2019; 21:2542-2552. [PMID: 31364233 PMCID: PMC6852173 DOI: 10.1111/dom.13840] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/08/2019] [Accepted: 07/25/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS The combination of basal insulin (BI) and GLP-1 receptor agonists (GLP-1RAs) is a rational and effective therapy for patients with uncontrolled type 2 diabetes (T2D). We compared the effectiveness of fixed and flexible BI/GLP-1RA combinations using routinely accumulated clinical data. METHODS This was a retrospective, multicentre, real-world study concerning T2D patients initiating a fixed or flexible BI/GLP-1RA combination (NCT03959865). The primary endpoint was change in HbA1c. Secondary endpoints were changes in body weight, fasting plasma glucose (FPG) and systolic blood pressure (SBP). Confounding was addressed by propensity score matching (PSM) or multivariable adjustment (MVA). RESULTS A total of 609 patients were included in the study, 131 in the fixed group and 478 in the flexible group. The two groups differed in terms of diabetes duration, body weight and concomitant medications. After 5.7 months, observed HbA1c reductions were 0.6% and 0.8%, and body weight reductions were 2.8 kg and 1.2 kg in the flexible and fixed groups, respectively. Following PSM, HbA1c declined similarly in the two groups, whereas reduction in body weight was significantly in favour of the flexible combination. Findings were robust in sensitivity analyses, with the exception that, with MVA, a significantly higher reduction in HbA1c was detected in the fixed group. Final doses of BI were higher in the fixed group, whereas those of GLP-1RA were higher in the flexible group. CONCLUSIONS In routine specialist care, initiation of the fixed or flexible BI/GLP-1RA combination allowed similar improvement in glycaemic control, but greater weight loss was observed with the flexible combination. This difference reflected dosages of BI and GLP-1RAs.
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Affiliation(s)
- Mario Luca Morieri
- Department of MedicineUniversity of PadovaPadovaItaly
- Division of Metabolic DiseasesPadova HospitalPadovaItaly
| | | | - Vera Frison
- Internal Medicine and Diabetology Service, ULSS6CittadellaItaly
| | | | | | | | | | - Annunziata Lapolla
- Department of MedicineUniversity of PadovaPadovaItaly
- Diabetology Service, ULSS6PadovaItaly
| | - Angelo Avogaro
- Department of MedicineUniversity of PadovaPadovaItaly
- Division of Metabolic DiseasesPadova HospitalPadovaItaly
| | - Gian Paolo Fadini
- Department of MedicineUniversity of PadovaPadovaItaly
- Division of Metabolic DiseasesPadova HospitalPadovaItaly
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Mosenzon O, Wiviott SD, Cahn A, Rozenberg A, Yanuv I, Goodrich EL, Murphy SA, Heerspink HJL, Zelniker TA, Dwyer JP, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Kato ET, Gause-Nilsson IAM, Fredriksson M, Johansson PA, Langkilde AM, Sabatine MS, Raz I. Effects of dapagliflozin on development and progression of kidney disease in patients with type 2 diabetes: an analysis from the DECLARE-TIMI 58 randomised trial. Lancet Diabetes Endocrinol 2019; 7:606-617. [PMID: 31196815 DOI: 10.1016/s2213-8587(19)30180-9] [Citation(s) in RCA: 430] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/10/2019] [Accepted: 05/10/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors have shown beneficial effects on renal outcomes mainly in patients with established atherosclerotic cardiovascular disease. Here we report analyses of renal outcomes with the SGLT2 inhibitor dapagliflozin in the DECLARE-TIMI 58 cardiovascular outcomes trial, which included patients with type 2 diabetes both with and without established atherosclerotic cardiovascular disease and mostly with preserved renal function. METHODS In DECLARE-TIMI 58, patients with type 2 diabetes, HbA1c 6·5-12·0% (47·5-113·1 mmol/mol), with either established atherosclerotic cardiovascular disease or multiple risk factors, and creatinine clearance of at least 60 mL/min were randomly assigned (1:1) to 10 mg dapagliflozin or placebo once daily. A prespecified secondary cardiorenal composite outcome was defined as a sustained decline of at least 40% in estimated glomerular filtration rate [eGFR] to less than 60 mL/min per 1·73m2, end-stage renal disease (defined as dialysis for at least 90 days, kidney transplantation, or confirmed sustained eGFR <15mL/min per 1·73 m2), or death from renal or cardiovascular causes; a prespecified renal-specific composite outcome was the same but excluding death from cardiovascular causes. In this renal analysis, we report findings for the components of these composite outcomes, subgroup analysis of these composite outcomes, and changes in eGFR at different timepoints. DECLARE-TIMI 58 is registered with ClinicalTrials.gov, number NCT01730534. FINDINGS The trial took place between April 25, 2013, and Sept 18, 2018; median follow-up was 4·2 years (IQR 3·9-4·4). Of the 17 160 participants who were randomly assigned, 8162 (47·6%) had an eGFR of at least 90 mL/min per 1·73 m2, 7732 (45·1%) had an eGFR of 60 to less than 90 mL/min per 1·73 m2, and 1265 (7·4%) had an eGFR of less than 60 mL/min per 1·73 m2 at baseline (one participant had missing data for eGFR); 6974 (40·6%) had established atherosclerotic cardiovascular disease and 10 186 (59·4%) had multiple risk factors. As previously reported, the cardiorenal secondary composite outcome was significantly reduced with dapagliflozin versus placebo (hazard ratio [HR] 0·76, 95% CI 0·67-0.87; p<0·0001); excluding death from cardiovascular causes, the HR for the renal-specific outcome was 0·53 (0·43-0·66; p<0·0001). We identified a 46% reduction in sustained decline in eGFR by at least 40% to less than 60 mL/min per 1·73 m2 (120 [1·4% vs 221 [2·6%]; HR 0·54 [95% CI 0·43-0·67]; p<0·0001). The risk of end-stage renal disease or renal death was lower in the dapagliflozin group than in the placebo group (11 [0·1%] vs 27 [0·3%]; HR 0·41 [95% CI 0·20-0·82]; p=0·012). Both the cardiorenal and renal-specific composite outcomes were improved with dapagliflozin versus placebo across various prespecified subgroups, including those defined by baseline eGFR (cardiorenal outcome pinteraction=0·97; renal-specific outcome pinteraction=0·87) and the presence or absence of established atherosclerotic cardiovascular disease (cardiorenal outcome pinteraction=0·67; renal-specific outcome pinteraction=0·72). 6 months after randomisation, the mean decrease in eGFR was larger in the dapagliflozin group than in the placebo group. The mean change equalised by 2 years, and at 3 and 4 years the mean decrease in eGFR was less with dapagliflozin than with placebo. INTERPRETATION Dapagliflozin seemed to prevent and reduce progression of kidney disease compared with placebo in this large and diverse population of patients with type 2 diabetes with and without established atherosclerotic cardiovascular disease, most of whom had preserved renal function. FUNDING AstraZeneca.
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Affiliation(s)
- Ofri Mosenzon
- Diabetes Unit, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Stephen D Wiviott
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Avivit Cahn
- Diabetes Unit, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aliza Rozenberg
- Diabetes Unit, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Erica L Goodrich
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Hiddo J L Heerspink
- University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Thomas A Zelniker
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jamie P Dwyer
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Eri T Kato
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | | | | | | | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Itamar Raz
- Diabetes Unit, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Fadini GP, Sciannameo V, Franzetti I, Bottigliengo D, D'Angelo P, Vinci C, Berchialla P, Arena S, Buzzetti R, Avogaro A. Similar effectiveness of dapagliflozin and GLP-1 receptor agonists concerning combined endpoints in routine clinical practice: A multicentre retrospective study. Diabetes Obes Metab 2019; 21:1886-1894. [PMID: 30985052 PMCID: PMC6767088 DOI: 10.1111/dom.13747] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 12/13/2022]
Abstract
AIMS According to cardiovascular outcome trials, some sodium-glucose contransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) are recommended for secondary cardiovascular prevention in type 2 diabetes (T2D). In this real-world study, we compared the simultaneous reductions in HbA1c, body weight and systolic blood pressure after initiation of dapagliflozin or GLP-1RA as second or a more advanced line of therapy. MATERIALS AND METHODS DARWIN-T2D was a retrospective multi-centre study conducted at diabetes specialist clinics in Italy that compared T2D patients who initiated dapagliflozin or GLP-1RA (exenatide once weekly or liraglutide). Data were collected at baseline and at the first follow-up visit after 3 to 12 months. The primary endpoint was the proportion of patients achieving a simultaneous reduction in HbA1c, body weight and systolic blood pressure. To reduce confounding, we used multivariable adjustment (MVA) or propensity score matching (PSM). RESULTS Totals of 473 patients initiating dapagliflozin and 336 patients initiating GLP-1RA were included. The two groups differed in age, diabetes duration, HbA1c, weight and concomitant medications. The median follow-up was 6 months in both groups. Using MVA or PSM, the primary endpoint was observed in 30% to 32% of patients, with no difference between groups. Simultaneous reduction of HbA1c, BP and SBP by specific threshold, as well as achievement of final goals, did not differ between groups. GLP-1RA reduced HbA1c by 0.3% more than the reduction achieved with dapagliflozin. CONCLUSION In routine specialist care, initiation of dapagliflozin can be as effective as initiation of a GLP-1RA for attainment of combined risk factor goals.
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Affiliation(s)
| | - Veronica Sciannameo
- Department of Cardiac, Thoracic and Vascular Sciences, Unit of Biostatistics, Epidemiology and Public HealthUniversity of PadovaPadovaItaly
| | - Ivano Franzetti
- Endocrinology Unit, ASST Valle OlonaSan Antonio Abate HospitalGallarateItaly
| | - Daniele Bottigliengo
- Department of Cardiac, Thoracic and Vascular Sciences, Unit of Biostatistics, Epidemiology and Public HealthUniversity of PadovaPadovaItaly
| | - Paola D'Angelo
- Diabetology UnitSandro Pertini Hospital, ASLRM 2RomeItaly
| | - Carmela Vinci
- Diabetology UnitAULSS 4 VenetoSan Donà di PiaveItaly
| | - Paola Berchialla
- Department of Clinical and Biological SciencesUniversity of TurinTurinItaly
| | - Salvatore Arena
- Unit of Endocrinology and Metabolic DiseasesUmberto I HospitalSiracusaItaly
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31
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Nguyen VT, Farman N, Palacios-Ramirez R, Sbeih M, Behar-Cohen F, Aractingi S, Jaisser F. Cutaneous Wound Healing in Diabetic Mice Is Improved by Topical Mineralocorticoid Receptor Blockade. J Invest Dermatol 2019; 140:223-234.e7. [PMID: 31278904 DOI: 10.1016/j.jid.2019.04.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 03/20/2019] [Accepted: 04/08/2019] [Indexed: 12/19/2022]
Abstract
Skin ulcers resulting from impaired wound healing are a serious complication of diabetes. Unresolved inflammation, associated with the dysregulation of both the phenotype and function of macrophages, is involved in the poor healing of diabetic wounds. Here, we report that topical pharmacological inhibition of the mineralocorticoid receptor (MR) by canrenoate or MR small interfering RNA can resolve inflammation to improve delayed skin wound healing in diabetic mouse models; importantly, wounds from normal mice are unaffected. The beneficial effect of canrenoate is associated with an increased ratio of anti-inflammatory M2 macrophages to proinflammatory M1 macrophages in diabetic wounds. Furthermore, we show that MR blockade leads to downregulation of the MR target, LCN2, which may facilitate macrophage polarization toward the M2 phenotype and improve impaired angiogenesis in diabetic wounds. Indeed, diabetic LCN2-deficient mice showed improved wound healing associated with macrophage M2 polarization and angiogenesis. In addition, recombinant LCN2 protein prevented IL-4-induced macrophage switch from M1 to M2 phenotype. In conclusion, topical MR blockade accelerates skin wound healing in diabetic mice via LCN2 reduction, M2 macrophage polarization, prevention of inflammation, and induction of angiogenesis.
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Affiliation(s)
- Van Tuan Nguyen
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, Paris, France; Laboratory of progenitors and endothelial cells during and after pregnancy, INSERM UMR 938, Centre de Recherche St Antoine, Sorbonne Université, Paris, France; Department of Basic Science, Thai Nguyen University of Agriculture and Forestry, Thainguyen, Vietnam
| | - Nicolette Farman
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, Paris, France
| | - Roberto Palacios-Ramirez
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, Paris, France
| | - Maria Sbeih
- Laboratory of progenitors and endothelial cells during and after pregnancy, INSERM UMR 938, Centre de Recherche St Antoine, Sorbonne Université, Paris, France
| | - Francine Behar-Cohen
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, Paris, France; Faculty of Medicine, Université Paris Descartes, Paris, France
| | - Sélim Aractingi
- Laboratory of progenitors and endothelial cells during and after pregnancy, INSERM UMR 938, Centre de Recherche St Antoine, Sorbonne Université, Paris, France; Faculty of Medicine, Université Paris Descartes, Paris, France; Department of Dermatology, Hôpital Cochin-Tarnier, Paris, France
| | - Frederic Jaisser
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, Paris, France; INSERM, Clinical Investigation Centre 1433, Vandoeuvre-lès-Nancy, France.
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32
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Fadini GP, Solini A, Manca ML, Penno G, Gatti A, Anichini R, Del Prato S, Avogaro A. Effectiveness of dapagliflozin versus comparators on renal endpoints in the real world: A multicentre retrospective study. Diabetes Obes Metab 2019; 21:252-260. [PMID: 30136354 PMCID: PMC6585815 DOI: 10.1111/dom.13508] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/07/2018] [Accepted: 08/18/2018] [Indexed: 12/13/2022]
Abstract
AIM To evaluate the changes in renal endpoints in type 2 diabetes patients treated with dapagliflozin versus other glucose-lowering medications in routine clinical practice. MATERIALS AND METHODS DARWIN-T2D was a retrospective study conducted at 46 outpatient diabetes clinics in Italy. An automated software collected data on 17 285 patients who received dapagliflozin, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, or gliclazide, 6751 of whom had a follow-up visit. We analysed changes in albumin excretion rate (AER) and estimated glomerular filtration rate (eGFR). RESULTS Patients who received dapagliflozin (n = 473) were younger, more obese, and had a poorer glucose control than those who received a comparator (n = 2973). After ~6 months, median (interquartile range) AER declined by 37%, from 19.5 (7.5-78.2) to 13.2 (6.5-45.0) mg/g (P < 0.0001) in the dapagliflozin group and did not change in the comparator group. After adjusting for confounders, therapy with dapagliflozin versus comparators was associated with an AER reduction of 26.4 ± 13.1 mg/g (P = 0.045), and eGFR (mL/min/1.73 m2 ) diminished by 1.1 ± 0.5 (P = 0.049) in the dapagliflozin group and by 0.6 ± 9.1 (P = 0.002) in the comparator group (P = 0.35 between groups). No patient treated with dapagliflozin versus four patients treated with comparators experienced a doubling of serum creatinine. CONCLUSIONS The antiproteinuric effect of dapagliflozin is confirmed here for the first time by real-world data. Despite a mild decline in eGFR, there was no evidence of clinically relevant worsening in renal function.
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Affiliation(s)
| | - Anna Solini
- Department of Surgical, Medical, Molecular and Critical Area PathologyUniversity of PisaPisaItaly
| | - Maria Laura Manca
- Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | - Giuseppe Penno
- Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | - Adriano Gatti
- Metabolic Disease Unit, San Gennaro HospitalNaplesItaly
| | - Roberto Anichini
- Diabetes Unit, Department of Internal MedicineSan Jacopo HospitalPistoiaItaly
| | - Stefano Del Prato
- Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
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