1
|
Miyamoto S, Heerspink HJL, de Zeeuw D, Sakamoto K, Yoshida M, Toyoda M, Suzuki D, Hatanaka T, Nakamura T, Kamei S, Murao S, Hida K, Ando S, Akai H, Takahashi Y, Kitada M, Sugano H, Nunoue T, Nakamura A, Sasaki M, Nakatou T, Fujimoto K, Kawanami D, Wada T, Miyatake N, Kuramoto H, Shikata K. A randomized, open-label, clinical trial examined the effects of canagliflozin on albuminuria and eGFR decline using an individual pre-intervention eGFR slope. Kidney Int 2024:S0085-2538(24)00625-2. [PMID: 39216659 DOI: 10.1016/j.kint.2024.08.019] [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: 03/03/2024] [Revised: 07/11/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024]
Abstract
Demonstrating drug efficacy in slowing kidney disease progression requires large clinical trials when targeting participants with an early stage of chronic kidney disease (CKD). In this randomized, parallel-group, open-labeled trial (CANPIONE study), we assessed the effect of the sodium-glucose cotransporter 2 (SGLT2) inhibitor canagliflozin using the individual's change in estimated glomerular filtration rate (eGFR) slope before (pre-intervention slope) and during treatment (chronic slope). We randomly assigned (1:1) participants with type 2 diabetes, urinary albumin-to-creatinine ratio (UACR) of 50 to under 300 mg/g, and an eGFR of at least 45 ml/min/1.73m2 to receive canagliflozin or guideline-recommended treatment except for SGLT2 inhibitors (control). The first and second primary outcomes were the geometric mean percentage change from baseline in UACR and the change in eGFR slope, respectively. Of 98 randomized participants, 96 received at least one study treatment. The least-squares mean change from baseline in log-transformed geometric mean UACR was significantly greater in the canagliflozin group than the control group (between group-difference, -30.8% (95% confidence interval -42.6 to -16.8). The between-group difference (canagliflozin group - control group) of change in eGFR slope (chronic - pre-intervention) was 4.4 (1.6 to 7.3) ml/min/1.73 m2 per year, which was more pronounced in participants with faster eGFR decline. In summary, canagliflozin reduced albuminuria and the participant-specific natural course of eGFR decline in participants with type 2 diabetes and microalbuminuria. Thus, the CANPIONE study suggests that the within-individual change in eGFR slope may be a novel approach to determine the kidney protective potential of new therapies in early stages of CKD.
Collapse
Affiliation(s)
- Satoshi Miyamoto
- Center for Innovative Clinical Medicine, Okayama University Hospital, Okayama, Japan; Department of Internal Medicine, Innoshima General Hospital, Onomichi, Japan.
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Kota Sakamoto
- Center for Innovative Clinical Medicine, Okayama University Hospital, Okayama, Japan
| | - Michihiro Yoshida
- Center for Innovative Clinical Medicine, Okayama University Hospital, Okayama, Japan
| | - Masao Toyoda
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | | | - Takashi Hatanaka
- Department of Diabetes and Endocrinology, National Hospital Organization Fukuyama Medical Center, Fukuyama, Japan
| | - Tohru Nakamura
- Diabetes Internal Medicine, Sumitomo Besshi Hospital, Nihama, Japan
| | - Shinji Kamei
- Department of Diabetic Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Satoshi Murao
- Department of Diabetes and Endocrinology, Takamatsu Hospital, Takamatsu, Japan
| | - Kazuyuki Hida
- Department of Diabetology and Metabolism, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Shinichiro Ando
- Department of Internal Medicine Diabetic Center, Okayama City Hospital, Okayama, Japan
| | - Hiroaki Akai
- Division of Diabetes and Metabolism, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | | | - Munehiro Kitada
- Department of Diabetology and Endocrinology, Kanazawa Medical University, Uchinada, Ishikawa, Japan; Division of Anticipatory Molecular Food Science and Technology, Medical Research Institute, Kanazawa Medical University, Uchinada, Ishikawa, Japan
| | - Hisashi Sugano
- Department of Diabetes and Endocrinology, Kochi Health Sciences Center, Kochi, Japan
| | | | | | - Motofumi Sasaki
- Department of Diabetes and Endocrinology, Matsue City Hospital, Matsue, Japan
| | - Tatsuaki Nakatou
- Diabetes Center, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Kei Fujimoto
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, The Jikei University Kashiwa Hospital, Kashiwa, Japan
| | - Daiji Kawanami
- Department of Endocrinology and Diabetes, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Nobuyuki Miyatake
- Department of Hygiene, Faculty of Medicine, Kagawa University, Miki, Kagawa, Japan
| | - Hiromi Kuramoto
- Center for Innovative Clinical Medicine, Okayama University Hospital, Okayama, Japan
| | - Kenichi Shikata
- Center for Innovative Clinical Medicine, Okayama University Hospital, Okayama, Japan
| |
Collapse
|
2
|
Chong KS, Chang YH, Lin MH, Hsu CN, Wang CC, Wang CY, Huang YL, Lin FJ, Ou HT. Kidney outcomes with SGLT2is for type 2 diabetes patients: does background treatment with metformin or RASis matter? Front Endocrinol (Lausanne) 2024; 15:1329945. [PMID: 38994012 PMCID: PMC11236716 DOI: 10.3389/fendo.2024.1329945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 06/10/2024] [Indexed: 07/13/2024] Open
Abstract
Introduction There is a lack of real-world evidence regarding the impact of concomitant metformin and renin-angiotensin system inhibitors (RASis) on sodium-glucose cotransporter-2 inhibitor (SGLT2i)-associated kidney outcomes. This study was aimed to investigate whether SGLT2i-associated kidney outcomes were modified by the concomitant use of metformin or RASis in patients with type 2 diabetes. Methods SGLT2i users were identified from three electronic health record databases during May 2016 and December 2017 and categorized into those with and without concomitant use of metformin or RASis. Propensity score matching was performed to minimize baseline differences between groups. Study outcomes were mean estimated glomerular filtration rate (eGFR) change and time to 30%, 40%, and 50% eGFR reductions. A meta-analysis was performed to combine the estimates across databases. Results After matching, there were 6,625 and 3,260 SGLT2i users with and without metformin, and 6,654 and 2,746 SGLT2i users with and without RASis, respectively. The eGFR dip was similar in SGLT2i users with and without metformin therapy, but was greater in SGLT2i users with RASis compared to those without RASis. Neither metformin nor RASi use had a significant effect on SGLT2i-associated eGFR reductions, as evidenced by the hazard ratios (95% CIs) of 30% eGFR reductions for SGLT2is with versus without metformin/RASis, namely 1.02 (0.87-1.20)/1.09 (0.92-1.31). Such findings were also observed in the outcomes of 40% and 50% eGFR reductions. Conclusion Using metformin or RASis did not modify SGLT2i-associated kidney outcomes in type 2 diabetes.
Collapse
Affiliation(s)
- Kah Suan Chong
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Hsin Chang
- 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
| | - Meng-Hsuan Lin
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- College of Pharmacy, Kaohsiung Medical University, Kaohsiung, 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
| | - Chih-Yuan Wang
- College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yun-Lin Huang
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - 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
| | - 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
| |
Collapse
|
3
|
Da Porto A, Bulfone L, Sechi L. Antihypertensive Effects of SGLT2-Inhibitors: Considerations for Clinical Practice. Curr Vasc Pharmacol 2024; 22:231-233. [PMID: 39300714 DOI: 10.2174/0115701611274645231208102130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/08/2023] [Accepted: 11/24/2023] [Indexed: 09/22/2024]
Affiliation(s)
- Andrea Da Porto
- Diabetes and Metabolism Unit, Clinica Medica, University of Udine, Italy
| | - Luca Bulfone
- ESH Excellence Hypertension Center, Clinica Medica, University of Udine, Italy
| | - Leonardo Sechi
- Diabetes and Metabolism Unit, Clinica Medica, University of Udine, Italy
- ESH Excellence Hypertension Center, Clinica Medica, University of Udine, Italy
| |
Collapse
|
4
|
Verma S, Mudaliar S, Greasley PJ. Potential Underlying Mechanisms Explaining the Cardiorenal Benefits of Sodium-Glucose Cotransporter 2 Inhibitors. Adv Ther 2024; 41:92-112. [PMID: 37943443 PMCID: PMC10796581 DOI: 10.1007/s12325-023-02652-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/17/2023] [Indexed: 11/10/2023]
Abstract
There is a bidirectional pathophysiological interaction between the heart and the kidneys, and prolonged physiological stress to the heart and/or the kidneys can cause adverse cardiorenal complications, including but not limited to subclinical cardiomyopathy, heart failure and chronic kidney disease. Whilst more common in individuals with Type 2 diabetes, cardiorenal complications also occur in the absence of diabetes. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) were initially approved to reduce hyperglycaemia in patients with Type 2 diabetes. Recently, these agents have been shown to significantly improve cardiovascular and renal outcomes in patients with and without Type 2 diabetes, demonstrating a robust reduction in hospitalisation for heart failure and reduced risk of progression of chronic kidney disease, thus gaining approval for use in treatment of heart failure and chronic kidney disease. Numerous potential mechanisms have been proposed to explain the cardiorenal effects of SGLT2i. This review provides a simplified summary of key potential cardiac and renal mechanisms underlying the cardiorenal benefits of SGT2i and explains these mechanisms in the clinical context. Key mechanisms related to the clinical effects of SGLT2i on the heart and kidneys explained in this publication include their impact on (1) tissue oxygen delivery, hypoxia and resultant ischaemic injury, (2) vascular health and function, (3) substrate utilisation and metabolic health and (4) cardiac remodelling. Knowing the mechanisms responsible for SGLT2i-imparted cardiorenal benefits in the clinical outcomes will help healthcare practitioners to identify more patients that can benefit from the use of SGLT2i.
Collapse
Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
| | - Sunder Mudaliar
- Endocrinology/Diabetes Section, Veterans Affairs Medical Centre, San Diego, CA, USA
- Department of Medicine, University of California, San Diego, CA, USA
| | - Peter J Greasley
- Early Discovery and Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| |
Collapse
|
5
|
Woodhams LM, Chalmers L, Sim TF, Yeap BB, Schlaich MP, Schultz C, Hillis GS. Efficacy and safety of sodium glucose cotransporter 2 inhibitors plus standard care in diabetic kidney disease: A systematic review and meta-analysis. J Diabetes Complications 2023; 37:108456. [PMID: 37127001 DOI: 10.1016/j.jdiacomp.2023.108456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Many people with type 2 diabetes progress to end-stage diabetic kidney disease (DKD) despite blockade of the renin-angiotensin system, suggesting the need for innovative treatment options for DKD. To capture the findings of recent studies, we performed an updated systematic review and meta-analysis of the efficacy and safety of sodium glucose co-transporter 2 (SGLT2) inhibitors combined with standard care involving angiotensin converting enzyme (ACE) inhibitors and/or angiotensin receptor blockers (ARBs) on the development and progression of DKD in people with type 2 diabetes compared with standard care alone. METHODS The Cochrane Library, MEDLINE, EMBASE, PubMed and clinical trials registers were systematically searched for randomized controlled trials published before 1 September 2022. Primary outcomes were urine albumin-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR). Secondary outcomes were glycated hemoglobin (HbA1c) and systolic blood pressure (SBP). Relative risk was calculated for adverse events. RESULTS Eight studies enrolling 5512 participants were included. In the meta-analysis (n = 1327), SGLT2 inhibitors were associated with a statistically significant reduction in UACR (weighted mean difference [WMD] -105.61 mg/g, 95 % CI -197.25 to -13.98, I2 = 99 %, p = 0.02). There was no statistically significant difference in relation to eGFR (n = 1375; WMD -0.23 mL/min/1.73m2, 95 % CI -4.34 to 3.89, I2 = 94 %, p = 0.91). CONCLUSIONS SGLT2 inhibitors in addition to standard care including ACE inhibitors and/or ARBs significantly reduced albuminuria, HbA1c and SBP when compared to standard care alone, supporting their routine use in people with type 2 diabetes.
Collapse
Affiliation(s)
- Louise M Woodhams
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia.
| | - Leanne Chalmers
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Tin Fei Sim
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Bu B Yeap
- Medical School, The University of Western Australia, Perth, Western Australia, Australia; Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Markus P Schlaich
- Medical School, The University of Western Australia, Perth, Western Australia, Australia; Dobney Hypertension Centre, Medical School, Royal Perth Hospital Unit/Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia; Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia; Neurovascular Hypertension and Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Carl Schultz
- Medical School, The University of Western Australia, Perth, Western Australia, Australia; Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Graham S Hillis
- Medical School, The University of Western Australia, Perth, Western Australia, Australia; Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| |
Collapse
|
6
|
Wang DD, Zhang C, Yang Y, He SM, Zhu P, Chen X. Effects of Sodium-Glucose Cotransporter-2 Inhibitors on Urine Albumin to Creatinine Ratio in Type 2 Diabetes Mellitus Patients and Medication Care. J Diabetes Res 2022; 2022:5854200. [PMID: 35910530 PMCID: PMC9328955 DOI: 10.1155/2022/5854200] [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: 04/06/2022] [Accepted: 07/11/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The purpose of this study was to explore the effects of sodium-glucose cotransporter-2 (SGLT-2) inhibitors on urine albumin to creatinine ratio (UACR) in type 2 diabetes mellitus (T2DM) patients and to recommend appropriate medication care scheme. METHODS 8371 T2DM patients from four dapagliflozin studies and two canagliflozin studies were collected for analyzing with nonlinear mixed effect model (NONMEM). The change rates of UACR from baseline were intended to be evaluation indicators. RESULTS In the present study, there was no significant difference in the effects on UACR using dapagliflozin or canagliflozin treatment in T2DM patients. The maximal effect (E max) and the treatment duration of reaching half of E max (ET50) from SGLT-2 inhibitors on UACR in T2DM patients were -19.2% and 0.448 weeks, respectively. Further, the treatment duration to reach 25%, 50%, 75%, and 80% E max was 0.150 weeks, 0.448 weeks, 1.344 weeks, and 1.792 weeks, respectively. Namely, for achieving the plateau period (80% of E max) of SGLT-2 inhibitors on UACR in T2DM patients, 10 mg/day dapagliflozin (or 100 mg/day canagliflozin) should be taken for at least 1.792 weeks. CONCLUSIONS To our knowledge, the present study explored the effects of SGLT-2 inhibitors on UACR in T2DM patients, meanwhile, recommended appropriate medication care scheme for the first time.
Collapse
Affiliation(s)
- Dong-Dong Wang
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy & School of Pharmacy, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Cun Zhang
- Department of Pharmacy, Xuzhou Oriental Hospital Affiliated to Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| | - Yang Yang
- Department of Pharmacy, The Affiliated Changzhou Children's Hospital of Nantong University, Changzhou 213003, China
| | - Su-Mei He
- Department of Pharmacy, The Affiliated Suzhou Science & Technology Town Hospital of Nanjing Medical University, Suzhou Jiangsu 215153, China
| | - Ping Zhu
- Department of Endocrinology, Huaian Hospital of Huaian City, Huaian, Jiangsu 223200, China
| | - Xiao Chen
- School of Nursing, Xuzhou Medical University, Xuzhou, Jiangsu 221004, China
| |
Collapse
|
7
|
Scheen AJ, Delanaye P. Acute renal injury events in diabetic patients treated with SGLT2 inhibitors: A comprehensive review with a special reference to RAAS blockers. DIABETES & METABOLISM 2021; 48:101315. [PMID: 34910981 DOI: 10.1016/j.diabet.2021.101315] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/03/2021] [Indexed: 01/13/2023]
Abstract
Renin-angiotensin-aldosterone system (RAAS) blockers and sodium-glucose cotransporter type 2 inhibitors (SGLT2is) are two pharmacological classes that proved a remarkable nephroprotective effect, yet a risk of acute kidney injury (AKI) was also pointed out. In 2016, the US Food and Drug Administration recommended caution with the concomitant use of these medications. While the literature devoted to RAAS blockers remained surprisingly limited, numerous articles were published in recent years with SGLT2is. Safety analyses of large prospective cardiorenal trials showed a reduced rather than an increased number of AKI events in patients with type 2 diabetes treated with SGLT2is compared with those treated with placebo, despite the fact that a majority of patients received RAAS blockers at baseline. Interestingly, retrospective observational studies confirmed these reassuring findings in real-life conditions in more heterogeneous and possibly more frailty populations also commonly treated with RAAS blockers by showing a reduced risk of AKI with SGLT2is compared with other glucose-lowering drugs. Currently, there are no evidence of an increased risk of AKI with RAAS blocker-SGLT2i combinations in absence of haemodynamic instability. Several underlying mechanisms could explain a decreased rather than an increased risk of AKI with SGLT2is, including in patients treated with RAAS blockers.
Collapse
Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, Liège, Belgium; Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège (ULiege), Liège, Belgium.
| | - Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège (ULiege), CHU Sart Tilman, Liège, Belgium; Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nîmes, France
| |
Collapse
|
8
|
Ravindran S, Munusamy S. Renoprotective mechanisms of sodium-glucose co-transporter 2 (SGLT2) inhibitors against the progression of diabetic kidney disease. J Cell Physiol 2021; 237:1182-1205. [PMID: 34713897 DOI: 10.1002/jcp.30621] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 10/02/2021] [Accepted: 10/08/2021] [Indexed: 12/19/2022]
Abstract
Sodium-glucose co-transporter 2 inhibitors (SGLT2-Is) have emerged as a promising class of antidiabetic drugs with cardioprotective and renoprotective effects in patients with type 2 diabetes (T2D). The sodium-glucose co-transporters 1 and 2 (SGLT 1 and SGLT2) located in the renal proximal tubules are responsible for glucose reabsorption from the glomerular filtrate back into the systemic circulation. Inhibition of SGLT2, which accounts for about 90% of the glucose reabsorption, leads to a significant reduction in blood glucose levels and a concomitant increase in the urinary excretion of glucose (glycosuria). Multiple mechanisms contribute to the nephroprotective effects of SGLT2-Is in T2D patients. These include: (1) Restoration of the tubuloglomerular feedback by increasing sodium delivery at macula densa, leading to afferent arteriolar constriction and reduced glomerular hyperfiltration, (2) Decreased activation of the intra-renal renin-angiotensin-aldosterone system, which also contributes to reducing glomerular hyperfiltration, (3) Increased production of ketone bodies, which serves as an alternate fuel for adenosine triphosphate production in mitochondria, which helps in attenuating inflammation, and (4) Protection against hypoxia, oxidative stress, and fibrosis. This review elaborates on the key mechanisms that underlie the nephroprotective effects and the adverse effects of SGLT2-Is in T2D patients with progressive diabetic kidney disease.
Collapse
Affiliation(s)
| | - Shankar Munusamy
- Department of Pharmaceutical and Administrative Sciences, Drake University College of Pharmacy and Health Sciences, Des Moines, Iowa, USA
| |
Collapse
|
9
|
Seidu S, Kunutsor SK, Topsever P, Khunti K. Benefits and harms of sodium-glucose co-transporter-2 inhibitors (SGLT2-I) and renin-angiotensin-aldosterone system inhibitors (RAAS-I) versus SGLT2-Is alone in patients with type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials. ENDOCRINOLOGY DIABETES & METABOLISM 2021; 5:e00303. [PMID: 34636161 PMCID: PMC8754244 DOI: 10.1002/edm2.303] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/19/2021] [Accepted: 09/21/2021] [Indexed: 01/22/2023]
Abstract
Introduction It is uncertain if the combination of sodium‐glucose co‐transporter 2 inhibitors (SGLT2‐Is) and renin‐angiotensin‐aldosterone system inhibitors (RAAS‐Is) provides better cardio‐renal clinical outcomes in people with type 2 diabetes mellitus (T2DM) compared with SGLT2‐Is alone. Using a systematic review and meta‐analysis of randomized controlled trials (RCTs), we evaluated the efficacy and safety with respect to cardio‐renal outcomes of the combination of SGLT2 and RAAS inhibitors vs SGLT2‐Is in patients with T2DM. Methods Studies were identified from MEDLINE, Embase, the Cochrane Library and search of bibliographies to May 2021. The Cochrane risk of bias tool was used to assess the risk of bias of each study. Study‐specific risk ratios (RRs) with 95% confidence intervals (CIs) were pooled. Quality of the evidence was assessed using GRADE. Results Nine articles comprising 8 RCT evaluations (n = 34,551 participants) that compared SGLT2‐Is with placebo in patients with T2DM against a background of standard care and reported subgroup results for those treated with or without RAAS‐Is at baseline were included. No RCT specifically investigated the combination of SGLT2 and RAAS inhibitors compared with SGLT2‐Is alone. The RRs (95% CIs) for composite cardiovascular outcome and composite CVD death/heart failure hospitalization comparing SGLT2‐Is vs placebo in patients on RAAS‐Is were 0.93 (0.85–1.01) and 0.88 (0.76–1.02), respectively. The corresponding estimates for patients not on RAAS‐Is were 0.78 (0.65–0.93) and 0.73 (0.65–0.82), respectively. There was no evidence of interactions between RAAS‐I status and the effects of SGLT2‐Is for both outcomes. Single study results showed that SGLT2‐Is vs placebo reduced the risk of composite kidney outcome and cardiovascular death in patients with RAAS inhibition. The effect of SGLT2 inhibition vs placebo on kidney parameters, genital infections, volume depletion, hyperkalaemia, hypokalaemia, hypoglycaemia and other adverse events was similar in patients with or without RAAS inhibition. The quality of the evidence ranged from very low to moderate. Conclusions Aggregate published data suggest that the combination of SGLT2 and RAAS inhibitors in the treatment of patients with T2DM may be similar in efficacy and safety if not superior to SGLT2‐Is alone. Head‐to‐head comparisons of the two interventions are warranted to inform T2DM management. The use of SGLT2 inhibition as a first‐line therapy in T2DM or its early use in the prevention of renal deterioration and cardiovascular complications in addition to its glycaemic control deserves further study.
Collapse
Affiliation(s)
- Samuel Seidu
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Setor K Kunutsor
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK.,Translational Health Sciences, Bristol Medical School, Learning & Research Building (Level 1), University of Bristol, Southmead Hospital, Bristol, UK
| | - Pinar Topsever
- Department of Family Medicine, Acibadem Mehmet Ali Aydinlar University School of Medicine, Kerem Aydinlar Campus, Atasehir, Turkey
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| |
Collapse
|
10
|
El-Sayed N, Mostafa YM, AboGresha NM, Ahmed AAM, Mahmoud IZ, El-Sayed NM. Dapagliflozin attenuates diabetic cardiomyopathy through erythropoietin up-regulation of AKT/JAK/MAPK pathways in streptozotocin-induced diabetic rats. Chem Biol Interact 2021; 347:109617. [PMID: 34391751 DOI: 10.1016/j.cbi.2021.109617] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/13/2021] [Accepted: 08/04/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE This study was designed to investigate the mechanism of Dapagliflozin (Dapa) cardioprotection against diabetic cardiomyopathy (DCM). Structural and functional changes in the heart as well as decrease of erythropoietin (EPO) levels were reported in DCM. EPO simultaneously activates three pathways: the Janus-activated kinase-signal transducer and activator of transcription (JAK2/STAT5), phosphatidylinositol-3-kinase-Akt (PI3K/Akt), and extracellular signal-related kinase (ERK/MAPK) cascades, that result in proliferation and differentiation of cardiac cells. METHODS AND RESULTS DCM was induced by a high fat diet for 10 weeks followed by administration of streptozotocin. After confirmation of diabetes, rats were divided randomly to 5 groups: Group 1; normal control group, Group 2; untreated diabetic group and Groups (3-5); diabetic groups received Dapa daily (0.75 mg, 1.5 or 3 mg/Kg, p.o) respectively for a month. At the end of the experiment, full anaesthesia was induced in all rats using ether inhalation and ECG was recorded. Blood samples were collected then rats were sacrificed and their heart were dissected out and processed for biochemical and histopathological studies. Untreated diabetic rats showed abnormal ECG pattern, elevation of serum cardiac enzymes, decrease EPO levels, downregulation of P-Akt, P-JAK2 and pMAPK pathways, abnormal histological structure of the heart and increase immunostaining intensity of P53 and TNF α in the cardiomyocytes. Dapa in a dose dependent manner attenuated the alterations in the previously mentioned parameters. CONCLUSION The cardioprotective effect of Dapa could be mediated by increasing EPO levels and activation of P-Akt, P-JAK2 and pMAPK signalling cascades which in turn decrease apoptosis.
Collapse
Affiliation(s)
- Nora El-Sayed
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Sinai University, Kantra Branch, Ismailia, Egypt
| | - Yasser M Mostafa
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Suez Canal University, Ismailia, 41522, Egypt; Department of Pharmacology & Toxicology, Faculty of Pharmacy, Badr University, Badr, Egypt
| | - Noha M AboGresha
- Department of Physiology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Amal A M Ahmed
- Department of Cytology & Histology, Faculty of Veterinary Medicine, Suez Canal University, Ismailia, Egypt
| | - Islam Z Mahmoud
- Department of Cardiovascular Medicine, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Norhan M El-Sayed
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Suez Canal University, Ismailia, 41522, Egypt.
| |
Collapse
|
11
|
Katsiki N, Dimitriadis GD, Mikhailidis DP. Serum Uric Acid and Diabetes: From Pathophysiology to Cardiovascular Disease. Curr Pharm Des 2021; 27:1941-1951. [PMID: 33397230 DOI: 10.2174/1381612827666210104124320] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 11/13/2020] [Indexed: 11/22/2022]
Abstract
Hyperuricemia, has been traditionally related to nephrolithiasis and gout. However, it has also been associated with the development of type 2 diabetes mellitus (T2DM) and cardiometabolic and cardiovascular diseases. Pathophysiologically, elevated serum uric acid (SUA) levels may be associated with abnormal lipid and glucose metabolism. In this narrative review, we consider the associations between hyperuricemia, hyperglycemia, atherosclerosis and thrombosis. Furthermore, we comment on the available evidence linking elevated SUA levels with the incidence and outcomes of coronary heart disease, stroke, peripheral artery disease and non-alcoholic fatty liver in subjects with T2DM. The effects of antidiabetic drugs (e.g. metformin, pioglitazone, sulfonylureas, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter 2 inhibitors and insulin) on SUA concentrations are also reviewed.
Collapse
Affiliation(s)
- Niki Katsiki
- First Department of Internal Medicine, Diabetes Center, Division of Endocrinology and Metabolism, AHEPA University Hospital, Thessaloniki, Greece
| | | | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital campus, University College London Medical School, University College London (UCL), London NW3 2QG, United Kingdom
| |
Collapse
|
12
|
Scholtes RA, van Baar MJB, Kok MD, Bjornstad P, Cherney DZI, Joles JA, van Raalte DH. Renal haemodynamic and protective effects of renoactive drugs in type 2 diabetes: Interaction with SGLT2 inhibitors. Nephrology (Carlton) 2021; 26:377-390. [PMID: 33283420 PMCID: PMC8026736 DOI: 10.1111/nep.13839] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/05/2020] [Accepted: 11/24/2020] [Indexed: 12/25/2022]
Abstract
Diabetic kidney disease remains the leading cause of end-stage kidney disease and a major risk factor for cardiovascular disease. Large cardiovascular outcome trials and dedicated kidney trials have shown that sodium-glucose cotransporter (SGLT)2 inhibitors reduce cardiovascular morbidity and mortality and attenuate hard renal outcomes in patients with type 2 diabetes (T2D). Underlying mechanisms explaining these renal benefits may be mediated by decreased glomerular hypertension, possibly by vasodilation of the post-glomerular arteriole. People with T2D often receive several different drugs, some of which could also impact the renal vasculature, and could therefore modify both renal efficacy and safety of SGLT2 inhibition. The most commonly prescribed drugs that could interact with SGLT2 inhibitors on renal haemodynamic function include renin-angiotensin system inhibitors, calcium channel blockers and diuretics. Herein, we review the effects of these drugs on renal haemodynamic function in people with T2D and focus on studies that measured glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) with gold-standard techniques. In addition, we posit, based on these observations, potential interactions with SGLT2 inhibitors with an emphasis on efficacy and safety.
Collapse
Affiliation(s)
- Rosalie A. Scholtes
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical CenterVU University Medical CenterAmsterdamThe Netherlands
| | - Michaël J. B. van Baar
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical CenterVU University Medical CenterAmsterdamThe Netherlands
| | - Megan D. Kok
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical CenterVU University Medical CenterAmsterdamThe Netherlands
| | - Petter Bjornstad
- Department of Pediatrics, Division of EndocrinologyUniversity of Colorado School of MedicineAuroraColoradoUSA
- Department of Medicine, Division of NephrologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - David Z. I. Cherney
- Department of Medicine and Department of Physiology, Division of Nephrology, University Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - Jaap A. Joles
- Department of Nephrology and HypertensionUniversity Medical CenterUtrechtThe Netherlands
| | - Daniël H. van Raalte
- Amsterdam Diabetes Center, Department of Internal Medicine, Academic Medical CenterVU University Medical CenterAmsterdamThe Netherlands
- Department of Vascular Medicine, Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| |
Collapse
|
13
|
Wheeler DC, James J, Patel D, Viljoen A, Ali A, Evans M, Fernando K, Hicks D, Milne N, Newland-Jones P, Wilding J. SGLT2 Inhibitors: Slowing of Chronic Kidney Disease Progression in Type 2 Diabetes. Diabetes Ther 2020; 11:2757-2774. [PMID: 32996085 PMCID: PMC7524028 DOI: 10.1007/s13300-020-00930-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/11/2020] [Indexed: 02/06/2023] Open
Abstract
Diabetic kidney disease (DKD) is a topic of increasing concern among clinicians involved in the management of type 2 diabetes mellitus (T2DM). It is a progressive and costly complication associated with increased risk of adverse cardiovascular (CV) and renal outcomes and mortality. Ongoing monitoring of the estimated glomerular filtration (eGFR) rate alongside the urine albumin:creatinine ratio (ACR) is recommended during regular T2DM reviews to enable a prompt DKD diagnosis or to assess disease progression, providing an understanding of adverse risk for each individual. Many people with DKD will progress to end-stage kidney disease (ESKD), requiring renal replacement therapy (RRT), typically haemodialysis or kidney transplantation. A range of lifestyle and pharmacological interventions is recommended to help lower CV risk, slow the advancement of DKD and prevent or delay the need for RRT. Emerging evidence concerning sodium-glucose co-transporter-2 inhibitor (SGLT2i) agents suggests a role for these medicines in slowing eGFR decline, enabling regression of albuminuria and reducing progression to ESKD. Improvements in renal end points observed in SGLT2i CV outcome trials (CVOTs) highlighted the possible impact of these agents in the management of DKD. Data from the canagliflozin CREDENCE trial (Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation) have since demonstrated the effectiveness of this medicine in reducing the risk of kidney failure and CV events in a population comprising individuals with T2DM and renal disease. CREDENCE was the first SGLT2i study to examine renal outcomes as the primary end point. Real-world studies have reaffirmed these outcomes in routine clinical practice. This article summarises the evidence regarding the use of SGLT2i medicines in slowing the progression of DKD and examines the possible mechanisms underpinning the renoprotective effects of these agents. The relevant national and international guidance for monitoring and treatment of DKD is also highlighted to help clinicians working to support this vulnerable group.
Collapse
Affiliation(s)
| | - June James
- University Hospitals of Leicester NHS Trust, University of Leicester, Leicester, UK
| | | | | | - Amar Ali
- Oakenhurst Medical Practice, Blackburn, UK
| | - Marc Evans
- University Hospital Llandough, Penarth, UK
| | | | | | - Nicola Milne
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | | |
Collapse
|
14
|
Scholtes RA, van Raalte DH, Correa‐Rotter R, Toto RD, Heerspink HJL, Cain V, Sjöström CD, Sartipy P, Stefánsson BV. The effects of dapagliflozin on cardio-renal risk factors in patients with type 2 diabetes with or without renin-angiotensin system inhibitor treatment: a post hoc analysis. Diabetes Obes Metab 2020; 22:549-556. [PMID: 31742881 PMCID: PMC7078964 DOI: 10.1111/dom.13923] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 11/14/2019] [Accepted: 11/14/2019] [Indexed: 12/31/2022]
Abstract
AIMS Renin-angiotensin system inhibitors (RASi) are the most effective treatments for diabetic kidney disease but significant residual renal risk remains, possibly because of other mechanisms of kidney disease progression unrelated to RAS that may be present. Sodium-glucose co-transporter-2 inhibitors reduce albuminuria and may complement RASi by offering additional renal protection. This post hoc analysis investigated the effects of dapagliflozin on cardio-renal risk factors in patients with type 2 diabetes (T2D) with increased albuminuria treated with or without RASi at baseline. MATERIALS AND METHODS We evaluated the effects of dapagliflozin 10 mg/day over 12-24 weeks across 13 placebo-controlled studies in patients with T2D with a urinary albumin-to-creatinine ratio (UACR) ≥30 mg/g at baseline. Patients were divided into two subgroups based on treatment with or without RASi at baseline. RESULTS Compared with patients with RASi at baseline (n = 957), patients without RASi (n = 302) were younger, had a shorter duration of diabetes (7 vs. 12 years), higher estimated glomerular filtration rate (eGFR) and lower UACR, serum uric acid (sUA), body weight and systolic blood pressure. Placebo-adjusted treatment effects of dapagliflozin on UACR, eGFR, glycated haemoglobin and haematocrit over 24 weeks were similar across groups. Mean reductions in body weight and sUA were more distinct in patients without RASi treatment at baseline. CONCLUSIONS Treatment with dapagliflozin over 24 weeks provides similar clinically relevant improvements in metabolic and haemodynamic parameters, and similar reductions in UACR, in patients with T2D with elevated albuminuria treated with or without RASi at baseline.
Collapse
Affiliation(s)
- Rosalie A. Scholtes
- Diabetes Centre, Department of Internal MedicineAmsterdam University Medical Centres, location VUmcAmsterdamThe Netherlands
| | - Daniël H. van Raalte
- Diabetes Centre, Department of Internal MedicineAmsterdam University Medical Centres, location VUmcAmsterdamThe Netherlands
| | - Ricardo Correa‐Rotter
- Nephrology and Mineral MetabolismNational Medical Science and Nutrition Institute Salvador ZubiránMexico CityMexico
| | - Robert D. Toto
- University of Texas Southwestern Medical CenterDallasTexasUnited States
| | - Hiddo J. L. Heerspink
- Clinical Pharmacy and Pharmacology, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Valerie Cain
- Bogier Clinical and IT Solutions Inc., RaleighNorth CarolinaUnited States
| | | | - Peter Sartipy
- AstraZenecaGothenburgSweden
- Systems Biology Research Center, School of BioscienceUniversity of SkövdeSkövdeSweden
| | | |
Collapse
|
15
|
|