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van Zuylen ML, Hermanides J, Hulst AH. Preoperative continuation of GLP-1 receptor agonists. Response to Br J Anaesth 2024; 133: 437-8. Br J Anaesth 2024:S0007-0912(24)00392-1. [PMID: 39030130 DOI: 10.1016/j.bja.2024.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 07/21/2024] Open
Affiliation(s)
- Mark L van Zuylen
- Department of Anaesthesiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands; Department of Paediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Abraham H Hulst
- Department of Anaesthesiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands.
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2
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Milder DA, Milder TY, Liang SS, Kam PCA. Glucagon-like peptide-1 receptor agonists: a narrative review of clinical pharmacology and implications for peri-operative practice. Anaesthesia 2024; 79:735-747. [PMID: 38740566 DOI: 10.1111/anae.16306] [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] [Accepted: 04/02/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Glucagon-like peptide-1 receptor agonists are used increasingly in the management of patients living with type 2 diabetes mellitus and obesity. In patients using glucagon-like peptide-1 receptor agonists, a key concern in the peri-operative period is the increased risk of pulmonary aspiration due to delayed gastric emptying. This review provides an overview of the pharmacodynamic and pharmacokinetic properties of glucagon-like peptide-1 receptor agonists and the risk of delayed gastric emptying and aspiration. METHODS We conducted searches of MEDLINE and EMBASE databases of articles published before January 2024 using the keywords and medical subject headings: incretins; glucagon-like peptide-1; GLP-1; glucagon-like peptide-1 receptor agonists; GLP-1 RA; peri-operative period; perioperative; peri-operative; stomach emptying; gastric emptying; pulmonary aspiration; aspiration; food regurgitation; and regurgitation. The evidence was analysed, synthesised and reported narratively. RESULTS A total of 1213 articles were located after duplicates were removed. Two authors screened the titles and abstracts to identify those studies which assessed specifically the risk of delayed gastric emptying and pulmonary aspiration or regurgitation in the peri-operative period. We searched manually the reference lists of relevant studies to identify any additional case reports. Ten studies were identified. Available evidence was limited to case reports, case series and observational work. CONCLUSIONS There is insufficient evidence to put forward definitive guidance regarding the ideal cessation period for glucagon-like peptide-1 receptor agonists before elective surgery. Precautionary practice is required until more evidence becomes available. We suggest an individualised, evidence-based approach. In patients living with type 2 diabetes mellitus, there is concern that prolonged cessation before surgery will have a detrimental effect on peri-operative glycaemic control and discussion with an endocrinologist is advised. For patients taking glucagon-like peptide-1 receptor agonists for weight management, these drugs should be withheld for at least three half-lives before an elective surgical procedure.
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Affiliation(s)
- David A Milder
- Department of Anaesthesia, Westmead Hospital, Westmead, NSW, Australia
| | - Tamara Y Milder
- Department of Diabetes and Endocrinology, St. Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Sophie S Liang
- Department of Anaesthesia, Westmead Hospital, Westmead, NSW, Australia
| | - Peter C A Kam
- Discipline of Anaesthesia, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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3
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Mendes FF, Carvalho LIM, Lopes MB. Glucagon-Like Peptide-1 agonists in perioperative medicine: to suspend or not to suspend, that is the question. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:844538. [PMID: 38944239 DOI: 10.1016/j.bjane.2024.844538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Affiliation(s)
- Florentino Fernandes Mendes
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Departamento de Clínica Cirúrgica, Programa de Pós-Graduação em Tecnologia da Informação e Gestão em Saúde, Porto Alegre, RS, Brazil.
| | - Lorena Ibiapina M Carvalho
- Hospital Prontomed, Teresina, PI, Brazil; Hospital Unimed Primavera, Departamento de Anestesiologia, Teresina, PI, Brazil
| | - Maristela Bueno Lopes
- Hospital São Marcelino Champagnat, Curitiba, PR, Brazil; Pontifícia Universidade Católica do Paraná, Departamento de Anestesiologia, Curitiba, PR, Brazil
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Oosterom-Eijmael MJP, Hermanides J, van Raalte DH, Kouw IWK, DeVries JH, Hulst AH. Continuous Glucose Monitoring and the Effect of Liraglutide in Cardiac Surgery Patients: A Substudy of the Randomized Controlled GLOBE Trial. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00385-9. [PMID: 38977382 DOI: 10.1053/j.jvca.2024.06.015] [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: 03/22/2024] [Revised: 05/23/2024] [Accepted: 06/11/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVES The objectives of the current research were to evaluate the accuracy and reliability of continuous glucose monitoring (CGM) in patients undergoing cardiac surgery and assess the impact of preoperative liraglutide administration on perioperative glucose control as captured by CGM. DESIGN This was a prospective, single-center, prespecified analysis of the GLOBE trial, a randomized controlled trial comparing preoperative liraglutide treatment to placebo in patients undergoing cardiac surgery. SETTING The work took place at a single-center academic hospital in the Netherlands. PARTICIPANTS Twenty-five patients undergoing cardiac surgery were recruited from the hospital's cardiac surgery department. INTERVENTIONS Participants received the Dexcom G5 CGM system from the day before surgery until discharge from the intensive care unit after surgery. Additionally, participants were randomized to receive either preoperative liraglutide or placebo. MEASUREMENTS AND MAIN RESULTS Arterial blood gas (ABG) glucose measurements were collected as a reference and matched to CGM readings to assess accuracy and reliability. In 240 paired CGM-ABG glucose measurements, the mean absolute relative difference was 14.4 ± 12.5%. Temporary sensor interruption occurred mainly intraoperatively (92% of patients). The median duration of intraoperative sensor interruption was 65 (48-95) minutes. Liraglutide increased glycemic time in range 72% versus 47% in the control group (absolute difference 25%, 95% confidence interval -41.4 to -8.9, p = .004). CONCLUSIONS Despite intraoperative sensor interruption, CGM seems an accurate method for semi-invasive, real-time assessment of blood glucose levels. CGM can provide a detailed observation of the pre- and postoperative glycemic trajectory, demonstrating increased time in range following perioperative liraglutide treatment compared with placebo.
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Affiliation(s)
- Maartina J P Oosterom-Eijmael
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Endocrinology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands.
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Daniël H van Raalte
- Department of Endocrinology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Imre W K Kouw
- Department of Intensive Care Medicine, Intensive Care Research, Gelderse Vallei Hospital, Ede, The Netherlands; Wageningen University & Research, Division of Human Nutrition and Health, Wageningen, The Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Abraham H Hulst
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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5
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Camilleri M, Lupianez-Merly C. Effects of GLP-1 and Other Gut Hormone Receptors on the Gastrointestinal Tract and Implications in Clinical Practice. Am J Gastroenterol 2024; 119:1028-1037. [PMID: 37753925 PMCID: PMC11026296 DOI: 10.14309/ajg.0000000000002519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/22/2023] [Indexed: 09/28/2023]
Abstract
Agonists targeting the receptors of incretin hormones, glucagon-like peptide-1 and glucose-dependent insulinotropic peptide, have been well established for the treatment of type 2 diabetes mellitus. There is increasing awareness that gastroenterologists and hepatologists should be treating obesity when patients present to their clinics. In addition, gastroenterologists and hepatologists should be aware of the effects of these classes of medications prescribed by other providers. Therefore, given the widespread use of incretin agonists for obesity treatment and weight loss, it is important to recognize their effects in the gastrointestinal tract, which could constitute significant benefits in weight loss and cardiometabolic benefits, but can be associated with adverse effects that constitute a potential barrier to their use, particularly at higher doses. Multiple studies reviewed in this article document the diverse effects of these drugs on the glucagon-like peptide-1 receptors that are widely expressed in the human body, including the nervous system modulating appetite, the gastrointestinal tract modifying gastric emptying, and lipid metabolism regulation leading to reduction in fat deposition. The objective of this review is to summarize the mechanism of action of incretin receptor agonists, their effects in the gastrointestinal tract, and implications in clinical practice, particularly in the practice of gastroenterology, endoscopy, and surgery.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Zöllner C. [Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]. DIE ANAESTHESIOLOGIE 2024; 73:294-323. [PMID: 38700730 PMCID: PMC11076399 DOI: 10.1007/s00101-024-01408-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Abstract
The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.
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Affiliation(s)
- Christian Zöllner
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Martinistr. 52, 20246, Hamburg, Deutschland.
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7
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Gebhardt B, Jain A. Beyond the Beat: A Cardiac Anesthesiologist's Perspective on Cardiovascular-Kidney-Metabolic Health in Perioperative Care. J Cardiothorac Vasc Anesth 2024; 38:1078-1080. [PMID: 38467526 DOI: 10.1053/j.jvca.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 03/13/2024]
Affiliation(s)
- Brian Gebhardt
- Department of Anesthesiology and Perioperative Medicine University of Massachusetts Medical Center, Worcester, MA
| | - Ankit Jain
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA
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8
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Jia M, Lv X, Zhu T, Shen JC, Liu WX, Yang JJ. Liraglutide ameliorates delirium-like behaviors of aged mice undergoing cardiac surgery by mitigating microglia activation via promoting mitophagy. Psychopharmacology (Berl) 2024; 241:687-698. [PMID: 37968531 DOI: 10.1007/s00213-023-06492-7] [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: 09/03/2023] [Accepted: 10/26/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE Postoperative delirium (POD) is a prevalent complication in cardiac surgery patients, particularly the elderly, with neuroinflammation posited as a crucial contributing factor. We investigated the prophylactic effects of liraglutide, a GLP-1 analog, on delirium-like behaviors in aged mice undergoing cardiac surgery and explored the underlying mechanisms focusing on neuroinflammation, mitochondrial dysfunction, and synaptic plasticity. METHODS Using a cardiac ischemia-reperfusion animal model to mimic cardiac surgery, we assessed delirium-like behaviors, microglial activation, NLRP3 inflammasome activation, mitophagy, synaptic engulfment, and synaptic plasticity. RESULTS Cardiac surgery triggered delirium-like behaviors, concomitant with heightened microglial and NLRP3 inflammasome activation and impaired mitochondrial function and synaptic plasticity. Pretreatment with liraglutide ameliorated these adverse outcomes. Mechanistically, liraglutide enhanced mitophagy, thereby inhibiting NLRP3 inflammasome activation and subsequent microglial activation. Furthermore, liraglutide counteracted surgery-induced synaptic loss and impairment of synaptic plasticity. CONCLUSION Liraglutide exerts protective effects against delirium-like behaviors in aged mice post-cardiac surgery, potentially through bolstering microglia mitophagy, curtailing neuroinflammation, and preserving synaptic integrity. This highlights the potential of liraglutide as a promising perioperative strategy for delirium prevention in cardiac surgery patients.
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Affiliation(s)
- Min Jia
- Department of Anesthesiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Lv
- Department of Anesthesiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China
| | - Tong Zhu
- Department of Anesthesiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China
| | - Jin-Chun Shen
- Department of Anesthesiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China.
| | - Wen-Xue Liu
- Department of Thoracic and Cardiovascular Surgery, Institute of Cardiothoracic Vascular Disease, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing University, Nanjing, China.
| | - Jian-Jun Yang
- Department of Anesthesiology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, 210002, China.
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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van Zuylen ML, Siegelaar SE, Plummer MP, Deane AM, Hermanides J, Hulst AH. Perioperative management of long-acting glucagon-like peptide-1 (GLP-1) receptor agonists: concerns for delayed gastric emptying and pulmonary aspiration. Br J Anaesth 2024; 132:644-648. [PMID: 38290907 DOI: 10.1016/j.bja.2024.01.001] [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: 09/13/2023] [Revised: 12/31/2023] [Accepted: 01/04/2024] [Indexed: 02/01/2024] Open
Abstract
Prescriptions and use of glucagon-like peptide-1 (GLP-1) receptor agonists are increasing dramatically, as indications are expanding from the treatment of diabetes mellitus to weight loss for people with obesity. As GLP-1 receptor agonists delay gastric emptying, perioperative healthcare practitioners could be concerned about an increased risk for pulmonary aspiration during general anaesthesia. We summarise relevant medical literature and provide evidence-based recommendations for perioperative care for people taking GLP-1 receptor agonists. GLP-1 receptor agonists delay gastric emptying; however, ongoing treatment attenuates this effect. The risk of aspiration during general anaesthesia is unknown. However, we advise caution in patients who recently commenced on GLP-1 receptor agonists. After over 12 weeks of treatment, standard fasting times likely suffice to manage the risk of pulmonary aspiration for most otherwise low-risk patients.
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Affiliation(s)
- Mark L van Zuylen
- Amsterdam UMC Location University of Amsterdam, Department of Anaesthesiology, Amsterdam, The Netherlands; Amsterdam UMC Location University of Amsterdam, Department of Paediatric Intensive Care, Emma Children's Hospital, Amsterdam, The Netherlands.
| | - Sarah E Siegelaar
- Amsterdam UMC Location University of Amsterdam, Department of Endocrinology and Metabolism, Amsterdam, The Netherlands; Research Institute, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, the Netherlands.
| | - Mark P Plummer
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia.
| | - Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia.
| | - Jeroen Hermanides
- Amsterdam UMC Location University of Amsterdam, Department of Anaesthesiology, Amsterdam, The Netherlands.
| | - Abraham H Hulst
- Amsterdam UMC Location University of Amsterdam, Department of Anaesthesiology, Amsterdam, The Netherlands; Research Institute, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, the Netherlands.
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Umpierrez G, Pasquel FJ, Duggan E, Galindo RJ. Should We Stop Glucagon-Like Peptide-1 Receptor Agonists Before Surgical or Endoscopic Procedures? Balancing Limited Evidence With Clinical Judgment. J Diabetes Sci Technol 2024:19322968241231565. [PMID: 38465586 DOI: 10.1177/19322968241231565] [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] [Indexed: 03/12/2024]
Abstract
The American Society of Anesthesiologists (ASA) Task Force recently recommended discontinuing glucagon-like peptide-1 receptor agonist (GLP-1 RA) agents before surgery because of the potential risk of pulmonary aspiration. However, there is limited scientific evidence to support this recommendation, and holding GLP-1 RA treatment may worsen glycemic control in patients with diabetes. As we await further safety data to manage GLP-1 RA in the perioperative period, we suggest an alternative multidisciplinary approach to manage patients undergoing elective surgery. Well-conducted observational and prospective studies are needed to determine the risk of pulmonary aspiration in persons receiving GLP-1 RA for the treatment of diabetes and obesity, as well as the short-term impact of discontinuing GLP-1 RA on glycemic control before elective procedures in persons with diabetes.
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Affiliation(s)
- Guillermo Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Francisco J Pasquel
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Elizabeth Duggan
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rodolfo J Galindo
- Division of Endocrinology, Department of Medicine, University of Miami, Miami, FL, USA
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11
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Liu W, Jia M, Zhang K, Chen J, Zhu X, Li R, Xu Z, Zang Y, Wang Y, Pan J, Ma D, Yang J, Wang D. Increased A1 astrocyte activation-driven hippocampal neural network abnormality mediates delirium-like behavior in aged mice undergoing cardiac surgery. Aging Cell 2024; 23:e14074. [PMID: 38155547 PMCID: PMC10928578 DOI: 10.1111/acel.14074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 12/30/2023] Open
Abstract
Delirium is the most common neurological complication after cardiac surgery with adverse impacts on surgical outcomes. Advanced age is an independent risk factor for delirium occurrence but its underlying mechanisms are not fully understood. Although increased A1 astrocytes and abnormal hippocampal networks are involved in neurodegenerative diseases, whether A1 astrocytes and hippocampal network changes are involved in the delirium-like behavior of aged mice remains unknown. In the present study, a mice model of myocardial ischemia-reperfusion mimicking cardiac surgery and various assessments were used to investigate the different susceptibility of the occurrence of delirium-like behavior between young and aged mice and the underlying mechanisms. The results showed that surgery significantly increased hippocampal A1 astrocyte activation in aged compared to young mice. The high neuroinflammatory state induced by surgery resulted in glutamate accumulation in the extrasynaptic space, which subsequently decreased the excitability of pyramidal neurons and increased the PV interneurons inhibition through enhancing N-methyl-D-aspartate receptors' tonic currents in the hippocampus. These further induced the abnormal activities of the hippocampal neural networks and consequently contributed to delirium-like behavior in aged mice. Notably, the intraperitoneal administration of exendin-4, a glucagon-like peptide-1 receptor agonist, downregulated A1 astrocyte activation and alleviated delirium-like behavior in aged mice, while IL-1α, TNF-α, and C1q in combination administered intracerebroventricularly upregulated A1 astrocyte activation and induced delirium-like behavior in young mice. Therefore, our study suggested that cardiac surgery increased A1 astrocyte activation which subsequently impaired the hippocampal neural networks and triggered delirium development.
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Affiliation(s)
- Wenxue Liu
- Department of Cardio‐Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Min Jia
- Department of Anesthesiology, Pain and Perioperative MedicineThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Keyin Zhang
- Department of Cardio‐Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Jiang Chen
- Ministry of Education Key Laboratory of Model Animal for Disease Study, Model Animal Research Center, Department of Neurology, Drum Tower Hospital, Medical SchoolNanjing UniversityNanjingChina
| | - Xiyu Zhu
- Department of Cardio‐Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Ruisha Li
- Department of Cardio‐Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Zhenjun Xu
- Department of Cardio‐Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Yanyu Zang
- Ministry of Education Key Laboratory of Model Animal for Disease Study, Model Animal Research CenterNanjing UniversityNanjingChina
| | - Yapeng Wang
- Department of Cardio‐Thoracic Surgery, Nanjing Drum Tower HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeNanjingChina
| | - Jun Pan
- Department of Cardio‐Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Daqing Ma
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of MedicineImperial College London, Chelsea and Westminster HospitalLondonUK
- Perioperative and Systems Medicine Laboratory, Children’s Hospital, Zhejiang University School of MedicineNational Clinical Research Center for Child HealthHangzhouChina
| | - Jianjun Yang
- Department of Anesthesiology, Pain and Perioperative MedicineThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Dongjin Wang
- Department of Cardio‐Thoracic Surgery, Institute of Cardiothoracic Vascular Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
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12
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Raven LM, Brown C, Greenfield JR. Considerations of delayed gastric emptying with peri-operative use of glucagon-like peptide-1 receptor agonists. Med J Aust 2024; 220:14-16. [PMID: 38009941 DOI: 10.5694/mja2.52170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/18/2023] [Indexed: 11/29/2023]
Affiliation(s)
- Lisa M Raven
- University of New South Wales, Sydney, NSW
- Garvan Institute of Medical Research, Sydney, NSW
- St Vincent's Hospital Sydney, Sydney, NSW
| | | | - Jerry R Greenfield
- University of New South Wales, Sydney, NSW
- Garvan Institute of Medical Research, Sydney, NSW
- St Vincent's Hospital Sydney, Sydney, NSW
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13
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Kokkorakis M, Katsarou A, Katsiki N, Mantzoros CS. Milestones in the journey towards addressing obesity; Past trials and triumphs, recent breakthroughs, and an exciting future in the era of emerging effective medical therapies and integration of effective medical therapies with metabolic surgery. Metabolism 2023; 148:155689. [PMID: 37689110 DOI: 10.1016/j.metabol.2023.155689] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 09/11/2023]
Abstract
The 21st century is characterized by an increasing incidence and prevalence of obesity and the burden of its associated comorbidities, especially cardiometabolic diseases, which are reaching pandemic proportions. In the late '90s, the "black box" of adipose tissue and energy homeostasis was opened with the discovery of leptin, transforming the adipose tissue from an "inert fat-storage organ" to the largest human endocrine organ and creating the basis on which more intensified research efforts to elucidate the pathogenesis of obesity and develop novel treatments were based upon. Even though leptin was eventually not proven to be the "standalone magic bullet" for the treatment of common/polygenic obesity, it has been successful in the treatment of monogenic obesity syndromes. Additionally, it shifted the paradigm of treating obesity from a condition due to "lack of willpower" to a disease due to distinct underlying biological mechanisms for which specific pharmacotherapies would be needed in addition to lifestyle modification. Subsequently, the melanocortin pathway proved to be an equally valuable pathway for the pharmacotherapy of obesity. Melanocortin receptor agonists have recently been approved for treating certain types of syndromic obesity. Other molecules- such as incretins, implicated in energy and glucose homeostasis- are secreted by the gastrointestinal tract. Glucagon-like peptide 1 (GLP-1) is the most prominent one, with GLP-1 analogs approved for common/polygenic obesity. Unimolecular combinations with other incretins, e.g., GLP-1 with gastric inhibitory polypeptide and/or glucagon, are expected to be approved soon as more effective pharmacotherapies for obesity and its comorbidities. Unimolecular combinations with other compounds and small molecules activating the receptors of these molecules are currently under investigation as promising future pharmacotherapies. Moreover, metabolic and bariatric surgery has also demonstrated impressive results, especially in the case of morbid obesity. Consequently, this broadening therapeutic armamentarium calls for a well-thought-after and well-coordinated multidisciplinary approach, for instance, through cardiometabolic expertise centers, that would ideally address effectively and cost-effectively obesity and its comorbidities, providing tangible benefits to large segments of the population.
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Affiliation(s)
- Michail Kokkorakis
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Angeliki Katsarou
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Niki Katsiki
- Department of Nutritional Sciences and Dietetics, International Hellenic University, 57400 Thessaloniki, Greece
| | - Christos S Mantzoros
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; Section of Endocrinology, VA Boston Healthcare System, Harvard Medical School, Boston, MA 02115, USA.
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14
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Wang H, Lin C, Zhang W, Wei F, Xu Y, Wang C. Effect of acute hypervolemic hemodilution with bicarbonated Ringer's solution on perioperative S100β and NSE in elderly patients undergoing spine surgery. Biotechnol Genet Eng Rev 2023:1-13. [PMID: 37224000 DOI: 10.1080/02648725.2023.2216970] [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: 02/28/2023] [Accepted: 05/18/2023] [Indexed: 05/26/2023]
Abstract
To explore the effect of acute hypervolemic hemodilution (AHH) with bicarbonated Ringer's solution (BRS) on perioperative serum S100β protein (S100β) and neuron-specific enolase (NSE) in elderly patients undergoing spine surgery. Ninety patients with lumbar spondylolisthesis and fracture surgery admitted to our hospital from January 2022 to August 2022 were selected as the study subjects, and they were randomly and equally divided into group H1 (AHH with BRS), group H2 (AHH with lactated Ringer's solution) and group C (no hemodilution). The serum contents of S100β and NSE of the three groups at different times were evaluated. There were significant differences in the incidence of postoperative cognitive dysfunction (POCD) among the three groups at T1 and T2 (P < 0.05). There were obvious differences in the contents of S100β and NSE among the three groups at T1 and T2 (P < 0.001), with no overt difference in the incidence of perioperative complications among the three groups (P > 0.05). The use of AHH with BRS can effectively reduce the effect on cognitive function in the elderly with spine surgery, which greatly reduces the nervous system injury, and has certain application value in clinic.
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Affiliation(s)
- Heng Wang
- Department of Anesthesiology, Yantaishan Hospital, Yantai, Shandong, China
| | - Changsen Lin
- Department of Anesthesiology, Affiliated Hospital of Shandong University of Traditional Chinese medicine, Jinan, Shandong, China
| | - Wenhong Zhang
- Department of Anesthesiology, Yantaishan Hospital, Yantai, Shandong, China
| | - Fujiang Wei
- Department of Anesthesiology, Yantaishan Hospital, Yantai, Shandong, China
| | - Yong Xu
- Department of Pharmacology, College of Basic Medicine, Binzhou Medical University, Yantai, China
| | - Chenghai Wang
- Department of Anesthesiology, Yantaishan Hospital, Yantai, Shandong, China
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15
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Crowley K, Scanaill PÓ, Hermanides J, Buggy DJ. Current practice in the perioperative management of patients with diabetes mellitus: a narrative review. Br J Anaesth 2023:S0007-0912(23)00128-9. [PMID: 37061429 PMCID: PMC10375498 DOI: 10.1016/j.bja.2023.02.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/08/2023] [Accepted: 02/23/2023] [Indexed: 04/17/2023] Open
Abstract
The prevalence of diabetes is increasing, and patients with diabetes mellitus have both an increased likelihood of requiring surgery and of developing postoperative complications when they do. We summarise available evidence underpinning current guidelines on preoperative assessment and optimisation, perioperative management of prescribed insulin and oral hypoglycaemic medication, intraoperative glycaemic control, and postoperative patient care.
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Affiliation(s)
- Kieran Crowley
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland.
| | - Pádraig Ó Scanaill
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland
| | | | - Donal J Buggy
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland; Outcomes Research Cleveland Clinic, Cleveland, OH, USA.
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16
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Sindhvananda W, Poopuangpairoj W, Jaiprasat T, Ongcharit P. Comparison of glucose control by added liraglutide to only insulin infusion in diabetic patient undergoing cardiac surgery: A preliminary randomized-controlled trial. Ann Card Anaesth 2023; 26:63-71. [PMID: 36722590 PMCID: PMC9997471 DOI: 10.4103/aca.aca_214_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background Liraglutide, glucagon-like peptide-1 (GLP-1) receptor agonist, has been investigated for safety and effectiveness for blood glucose (BG) control in a surgical setting. However, there are only a few studies specific to cardiac surgery patients. Aims To primarily compare perioperative 1) BG and 2) glycemic variability (GV) between added liraglutide and only insulin infusion in diabetes mellitus (DM) patients undergoing cardiac surgery. Setting and Design A randomized control trial was conducted in DM patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Inclusion criteria were age 20-80 years and DM Type 2. Material and Methods : The recruited patients were randomly assigned to Group 1 (added liraglutide with insulin infusion) and Group 2 (insulin infusion). Insulin infusion was based on institutional protocol. Point of care testing (POCT) glucose was used for the adjustment of insulin and BG analysis. Continuous glucose monitor (CGM) was for GV analysis (using Standard deviation: SD). Statistics : t-test, Chi-square or Fisher-exact test, or Mann-Whitney U test. Results : Finally, 60 patients were in our study (Group 1 = 32 vs Group 2 = 28). Perioperative mean BG levels of Group 1 were significantly lower than Group 2 with a mean difference of 15.9 mg/dL. Nine patients (18.7% vs 10.7%, P = 0.384) had BG of 60-70 with mean BGs (109.1 vs 147.9, P = 0.001) in the morning. Thirteen patients (9.4% vs 35.7%, P = 0.025) had BG >180 mg/dL at the 1st operative hour. SDs were increasing, but lower SD of Group 1 were observed at the postoperative period. Mean of SDs at postoperative day 2 were 23.65 vs 32.79 mg/dL, P = 0.018. Conclusions : Liraglutide added with insulin infusion can attenuate perioperative BG and is beneficial in the aspect of lowering GV together with BG at the postoperative period in DM patients. Liraglutide can be applied in cardiac surgery but a rearrangement of time and dosage should be further investigated.
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Affiliation(s)
- Wacharin Sindhvananda
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Rama IV, Bangkok, Thailand
| | - Weerasake Poopuangpairoj
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Rama IV, Bangkok, Thailand
| | - Teerarat Jaiprasat
- Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Rama IV, Bangkok, Thailand
| | - Pachara Ongcharit
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Rama IV, Bangkok, Thailand
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17
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Kietaibl AT, Huber J, Clodi M, Abrahamian H, Ludvik B, Fasching P. [Position statement: surgery and diabetes mellitus (Update 2023)]. Wien Klin Wochenschr 2023; 135:256-271. [PMID: 37101047 PMCID: PMC10133078 DOI: 10.1007/s00508-022-02121-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 04/28/2023]
Abstract
This position statement reflects the perspective of the Austrian Diabetes Association concerning the perioperative management of people with diabetes mellitus based on the available scientific evidence. The paper covers necessary preoperative examinations from an internal/diabetological point of view as well as the perioperative metabolic control by means of oral antihyperglycemic and/or insulin therapy.
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Affiliation(s)
- Antonia-Therese Kietaibl
- 5. Medizinische Abteilung für Endokrinologie, Rheumatologie und Akutgeriatrie, Klinik Ottakring, Wien, Österreich
| | - Joakim Huber
- Interne Abteilung mit Akutgeriatrie und Palliativmedizin, Franziskus Spital, Standort Landstraße, Wien, Österreich
| | - Martin Clodi
- ICMR - Institute for Cardiovascular and Metabolic Research, Johannes Kepler Universität Linz, Linz, Österreich.
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich.
| | | | - Bernhard Ludvik
- 1. Medizinische Abteilung für Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
| | - Peter Fasching
- 5. Medizinische Abteilung für Endokrinologie, Rheumatologie und Akutgeriatrie, Klinik Ottakring, Wien, Österreich
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18
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Chaudhry A, Roels C, Lee J. Sodium-Glucose Cotransporter-2 Inhibitor-associated Euglycemic Diabetic Ketoacidosis: Lessons From a Case Series of 4 Patients Undergoing Coronary Artery Bypass Grafting Surgery. Can J Diabetes 2022; 46:843-850. [PMID: 36068154 DOI: 10.1016/j.jcjd.2022.06.007] [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: 04/07/2022] [Revised: 05/06/2022] [Accepted: 06/15/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Euglycemic diabetic ketoacidosis (DKA) is a potentially life-threatening adverse condition associated with use of sodium-glucose cotransporter-2 inhibitors (SGLT2i). This risk is further pronounced in the perioperative period. There is no consensus for when SGLT2i should be held preoperatively, and recommendations from various organizations have evolved from 1 day to 3 to 4 days in the latest American Diabetes Association guidelines. Further study of patients with perioperative euglycemic DKA is required to help clarify the optimal timing of preoperative discontinuation of SGLT2i agents. METHODS In this retrospective, single-centre case series we examined 4 patients who developed postoperative euglycemic DKA after coronary artery bypass grafting, 3 of whom underwent semiurgent surgery. We characterized their clinical course, predisposing factors and treatment characteristics. RESULTS The SGLT2i were held for 1 to 5 days preoperatively, with times since last dose before surgery being 54, 79, 80 and 151 hours. Surgery was semiurgent for 3 patients, and elective for 1 patient. Three patients were diagnosed with euglycemic DKA within 24 hours after surgery. The fourth patient developed euglycemic DKA on postoperative day 3 in the context of significant hypovolemia and exhibited potential signs of protracted SGLT2i action at 7 days since the last dose. CONCLUSIONS The duration of SGLT2i action and risk for DKA is variable and complex. Providers should hold SGLT2i at least 3 days before elective major surgery, with potentially longer times in high-risk patients. Careful vigilance should be used for perioperative DKA development in all patients recently exposed to SGLT2i.
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Affiliation(s)
- Ahsen Chaudhry
- Division of Endocrinology, Department of Medicine, University of British Columbia, Burnaby, British Columbia, Canada.
| | - Craig Roels
- Lower Mainland Pharmacy Services, Fraser Health Authority, New Westminster, British Columbia, Canada
| | - Julie Lee
- Division of Endocrinology, Department of Medicine, University of British Columbia, Burnaby, British Columbia, Canada
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19
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Blonde L, Umpierrez GE, Reddy SS, McGill JB, Berga SL, Bush M, Chandrasekaran S, DeFronzo RA, Einhorn D, Galindo RJ, Gardner TW, Garg R, Garvey WT, Hirsch IB, Hurley DL, Izuora K, Kosiborod M, Olson D, Patel SB, Pop-Busui R, Sadhu AR, Samson SL, Stec C, Tamborlane WV, Tuttle KR, Twining C, Vella A, Vellanki P, Weber SL. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract 2022; 28:923-1049. [PMID: 35963508 PMCID: PMC10200071 DOI: 10.1016/j.eprac.2022.08.002] [Citation(s) in RCA: 144] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers. METHODS The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development. RESULTS This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes. CONCLUSIONS This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.
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Affiliation(s)
| | | | - S Sethu Reddy
- Central Michigan University, Mount Pleasant, Michigan
| | | | | | | | | | | | - Daniel Einhorn
- Scripps Whittier Diabetes Institute, La Jolla, California
| | | | | | - Rajesh Garg
- Lundquist Institute/Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | | | - Darin Olson
- Colorado Mountain Medical, LLC, Avon, Colorado
| | | | | | - Archana R Sadhu
- Houston Methodist; Weill Cornell Medicine; Texas A&M College of Medicine; Houston, Texas
| | | | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | | | - Katherine R Tuttle
- University of Washington and Providence Health Care, Seattle and Spokane, Washington
| | | | | | | | - Sandra L Weber
- University of South Carolina School of Medicine-Greenville, Prisma Health System, Greenville, South Carolina
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20
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Kanie T, Mizuno A, Takaoka Y, Suzuki T, Yoneoka D, Nishikawa Y, Tam WWS, Morze J, Rynkiewicz A, Xin Y, Wu O, Providencia R, Kwong JS. Dipeptidyl peptidase-4 inhibitors, glucagon-like peptide 1 receptor agonists and sodium-glucose co-transporter-2 inhibitors for people with cardiovascular disease: a network meta-analysis. Cochrane Database Syst Rev 2021; 10:CD013650. [PMID: 34693515 PMCID: PMC8812344 DOI: 10.1002/14651858.cd013650.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is a leading cause of death globally. Recently, dipeptidyl peptidase-4 inhibitors (DPP4i), glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose co-transporter-2 inhibitors (SGLT2i) were approved for treating people with type 2 diabetes mellitus. Although metformin remains the first-line pharmacotherapy for people with type 2 diabetes mellitus, a body of evidence has recently emerged indicating that DPP4i, GLP-1RA and SGLT2i may exert positive effects on patients with known CVD. OBJECTIVES To systematically review the available evidence on the benefits and harms of DPP4i, GLP-1RA, and SGLT2i in people with established CVD, using network meta-analysis. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and the Conference Proceedings Citation Index on 16 July 2020. We also searched clinical trials registers on 22 August 2020. We did not restrict by language or publication status. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) investigating DPP4i, GLP-1RA, or SGLT2i that included participants with established CVD. Outcome measures of interest were CVD mortality, fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, all-cause mortality, hospitalisation for heart failure (HF), and safety outcomes. DATA COLLECTION AND ANALYSIS Three review authors independently screened the results of searches to identify eligible studies and extracted study data. We used the GRADE approach to assess the certainty of the evidence. We conducted standard pairwise meta-analyses and network meta-analyses by pooling studies that we assessed to be of substantial homogeneity; subgroup and sensitivity analyses were also pursued to explore how study characteristics and potential effect modifiers could affect the robustness of our review findings. We analysed study data using the odds ratios (ORs) and log odds ratios (LORs) with their respective 95% confidence intervals (CIs) and credible intervals (Crls), where appropriate. We also performed narrative synthesis for included studies that were of substantial heterogeneity and that did not report quantitative data in a usable format, in order to discuss their individual findings and relevance to our review scope. MAIN RESULTS We included 31 studies (287 records), of which we pooled data from 20 studies (129,465 participants) for our meta-analysis. The majority of the included studies were at low risk of bias, using Cochrane's tool for assessing risk of bias. Among the 20 pooled studies, six investigated DPP4i, seven studied GLP-1RA, and the remaining seven trials evaluated SGLT2i. All outcome data described below were reported at the longest follow-up duration. 1. DPP4i versus placebo Our review suggests that DPP4i do not reduce any risk of efficacy outcomes: CVD mortality (OR 1.00, 95% CI 0.91 to 1.09; high-certainty evidence), myocardial infarction (OR 0.97, 95% CI 0.88 to 1.08; high-certainty evidence), stroke (OR 1.00, 95% CI 0.87 to 1.14; high-certainty evidence), and all-cause mortality (OR 1.03, 95% CI 0.96 to 1.11; high-certainty evidence). DPP4i probably do not reduce hospitalisation for HF (OR 0.99, 95% CI 0.80 to 1.23; moderate-certainty evidence). DPP4i may not increase the likelihood of worsening renal function (OR 1.08, 95% CI 0.88 to 1.33; low-certainty evidence) and probably do not increase the risk of bone fracture (OR 1.00, 95% CI 0.83 to 1.19; moderate-certainty evidence) or hypoglycaemia (OR 1.11, 95% CI 0.95 to 1.29; moderate-certainty evidence). They are likely to increase the risk of pancreatitis (OR 1.63, 95% CI 1.12 to 2.37; moderate-certainty evidence). 2. GLP-1RA versus placebo Our findings indicate that GLP-1RA reduce the risk of CV mortality (OR 0.87, 95% CI 0.79 to 0.95; high-certainty evidence), all-cause mortality (OR 0.88, 95% CI 0.82 to 0.95; high-certainty evidence), and stroke (OR 0.87, 95% CI 0.77 to 0.98; high-certainty evidence). GLP-1RA probably do not reduce the risk of myocardial infarction (OR 0.89, 95% CI 0.78 to 1.01; moderate-certainty evidence), and hospitalisation for HF (OR 0.95, 95% CI 0.85 to 1.06; high-certainty evidence). GLP-1RA may reduce the risk of worsening renal function (OR 0.61, 95% CI 0.44 to 0.84; low-certainty evidence), but may have no impact on pancreatitis (OR 0.96, 95% CI 0.68 to 1.35; low-certainty evidence). We are uncertain about the effect of GLP-1RA on hypoglycaemia and bone fractures. 3. SGLT2i versus placebo This review shows that SGLT2i probably reduce the risk of CV mortality (OR 0.82, 95% CI 0.70 to 0.95; moderate-certainty evidence), all-cause mortality (OR 0.84, 95% CI 0.74 to 0.96; moderate-certainty evidence), and reduce the risk of HF hospitalisation (OR 0.65, 95% CI 0.59 to 0.71; high-certainty evidence); they do not reduce the risk of myocardial infarction (OR 0.97, 95% CI 0.84 to 1.12; high-certainty evidence) and probably do not reduce the risk of stroke (OR 1.12, 95% CI 0.92 to 1.36; moderate-certainty evidence). In terms of treatment safety, SGLT2i probably reduce the incidence of worsening renal function (OR 0.59, 95% CI 0.43 to 0.82; moderate-certainty evidence), and probably have no effect on hypoglycaemia (OR 0.90, 95% CI 0.75 to 1.07; moderate-certainty evidence) or bone fracture (OR 1.02, 95% CI 0.88 to 1.18; high-certainty evidence), and may have no impact on pancreatitis (OR 0.85, 95% CI 0.39 to 1.86; low-certainty evidence). 4. Network meta-analysis Because we failed to identify direct comparisons between each class of the agents, findings from our network meta-analysis provided limited novel insights. Almost all findings from our network meta-analysis agree with those from the standard meta-analysis. GLP-1RA may not reduce the risk of stroke compared with placebo (OR 0.87, 95% CrI 0.75 to 1.0; moderate-certainty evidence), which showed similar odds estimates and wider 95% Crl compared with standard pairwise meta-analysis. Indirect estimates also supported comparison across all three classes. SGLT2i was ranked the best for CVD and all-cause mortality. AUTHORS' CONCLUSIONS Findings from both standard and network meta-analyses of moderate- to high-certainty evidence suggest that GLP-1RA and SGLT2i are likely to reduce the risk of CVD mortality and all-cause mortality in people with established CVD; high-certainty evidence demonstrates that treatment with SGLT2i reduce the risk of hospitalisation for HF, while moderate-certainty evidence likely supports the use of GLP-1RA to reduce fatal and non-fatal stroke. Future studies conducted in the non-diabetic CVD population will reveal the mechanisms behind how these agents improve clinical outcomes irrespective of their glucose-lowering effects.
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Affiliation(s)
- Takayoshi Kanie
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Atsushi Mizuno
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
- Penn Medicine Nudge Unit, University of Pennsylvania Philadelphia, Philadelphia, PA, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Yoshimitsu Takaoka
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Takahiro Suzuki
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Daisuke Yoneoka
- Division of Biostatistics and Bioinformatics, Graduate School of Public Health, St. Luke's International University, Tokyo, Japan
| | - Yuri Nishikawa
- Department of Gerontological Nursing and Healthcare Systems Management, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Gerontological Nursing, Kyorin University, Tokyo, Japan
| | - Wilson Wai San Tam
- Alice Lee Center for Nursing Studies, NUS Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Jakub Morze
- Department of Human Nutrition, University of Warmia and Mazury, Olsztyn, Poland
| | - Andrzej Rynkiewicz
- Department of Cardiology and Cardiosurgery, School of Medicine, University of Warmia and Mazury, Olsztyn, Poland
| | - Yiqiao Xin
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Rui Providencia
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
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21
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Pfeifer KJ, Selzer A, Mendez CE, Whinney CM, Rogers B, Simha V, Regan D, Urman RD, Mauck K. Preoperative Management of Endocrine, Hormonal, and Urologic Medications: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc 2021; 96:1655-1669. [PMID: 33714600 DOI: 10.1016/j.mayocp.2020.10.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/25/2020] [Accepted: 10/02/2020] [Indexed: 12/21/2022]
Abstract
Perioperative medical management is challenging due to the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources utilize the recommendations derived from individual studies and do not include a multidisciplinary focus or formal consensus. The Society for Perioperative Assessment and Quality Improvement (SPAQI) identified a lack of authoritative clinical guidance as an opportunity to utilize its multidisciplinary membership to improve evidence-based perioperative care. SPAQI seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this Consensus Statement is to provide practical guidance on the preoperative management of endocrine, hormonal, and urologic medications. A panel of experts with anesthesiology, perioperative medicine, hospital medicine, general internal medicine, and medical specialty experience was drawn together and identified the common medications in each of these categories. The authors then utilized a modified Delphi approach to critically review the literature and generate consensus recommendations.
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Affiliation(s)
- Kurt J Pfeifer
- Department of Medicine, Medical College of Wisconsin, Milwaukee.
| | - Angela Selzer
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora
| | - Carlos E Mendez
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | | | - Barbara Rogers
- Department of Anesthesiology, The Ohio State Wexner Medical Center, Columbus
| | - Vinaya Simha
- Division of Endocrinology, Mayo Clinic, Rochester, MN
| | - Dennis Regan
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Karen Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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22
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Pasquel FJ, Lansang MC, Dhatariya K, Umpierrez GE. Management of diabetes and hyperglycaemia in the hospital. Lancet Diabetes Endocrinol 2021; 9:174-188. [PMID: 33515493 PMCID: PMC10423081 DOI: 10.1016/s2213-8587(20)30381-8] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 10/25/2020] [Accepted: 11/02/2020] [Indexed: 01/08/2023]
Abstract
Hyperglycaemia in people with and without diabetes admitted to the hospital is associated with a substantial increase in morbidity, mortality, and health-care costs. Professional societies have recommended insulin therapy as the cornerstone of inpatient pharmacological management. Intravenous insulin therapy is the treatment of choice in the critical care setting. In non-intensive care settings, several insulin protocols have been proposed to manage patients with hyperglycaemia; however, meta-analyses comparing different treatment regimens have not clearly endorsed the benefits of any particular strategy. Clinical guidelines recommend stopping oral antidiabetes drugs during hospitalisation; however, in some countries continuation of oral antidiabetes drugs is commonplace in some patients with type 2 diabetes admitted to hospital, and findings from clinical trials have suggested that non-insulin drugs, alone or in combination with basal insulin, can be used to achieve appropriate glycaemic control in selected populations. Advances in diabetes technology are revolutionising day-to-day diabetes care and work is ongoing to implement these technologies (ie, continuous glucose monitoring, automated insulin delivery) for inpatient care. Additionally, transformations in care have occurred during the COVID-19 pandemic, including the use of remote inpatient diabetes management-research is needed to assess the effects of such adaptations.
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Affiliation(s)
- Francisco J Pasquel
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - M Cecilia Lansang
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Guillermo E Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Cardona S, Tsegka K, Pasquel FJ, Jacobs S, Halkos M, Keeling WB, Davis GM, Fayfman M, Albury B, Urrutia MA, Galindo RJ, Migdal AL, Macheers S, Guyton RA, Vellanki P, Peng L, Umpierrez GE. Sitagliptin for the prevention and treatment of perioperative hyperglycaemia in patients with type 2 diabetes undergoing cardiac surgery: A randomized controlled trial. Diabetes Obes Metab 2021; 23:480-488. [PMID: 33140566 PMCID: PMC8573668 DOI: 10.1111/dom.14241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/02/2020] [Accepted: 10/25/2020] [Indexed: 12/14/2022]
Abstract
AIM To assess whether treatment with sitagliptin, starting before surgery and continued during the hospital stay, can prevent and reduce the severity of perioperative hyperglycaemia in patients with type 2 diabetes undergoing coronary artery bypass graft (CABG) surgery. MATERIALS AND METHODS We conducted a double-blinded, placebo-controlled trial in adults with type 2 diabetes randomly assigned to receive sitagliptin or matching placebo starting 1 day prior to surgery and continued during the hospital stay. The primary outcome was difference in the proportion of patients with postoperative hyperglycaemia (blood glucose [BG] > 10 mmol/L [>180 mg/dL]) in the intensive care unit (ICU). Secondary endpoints included differences in mean daily BG in the ICU and after transition to regular wards, hypoglycaemia, hospital complications, length of stay and need of insulin therapy. RESULTS We included 182 participants randomized to receive sitagliptin or placebo (91 per group, age 64 ± 9 years, HbA1c 7.6% ± 1.5% and diabetes duration 10 ± 9 years). There were no differences in the number of patients with postoperative BG greater than 10 mmol/L, mean daily BG in the ICU or after transition to regular wards, hypoglycaemia, hospital complications or length of stay. There were no differences in insulin requirements in the ICU; however, sitagliptin therapy was associated with lower mean daily insulin requirements (21.1 ± 18.4 vs. 32.5 ± 26.3 units, P = .007) after transition to a regular ward compared with placebo. CONCLUSION The administration of sitagliptin prior to surgery and during the hospital stay did not prevent perioperative hyperglycaemia or complications after CABG. Sitagliptin therapy was associated with lower mean daily insulin requirements after transition to regular wards.
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Affiliation(s)
| | | | | | - Sol Jacobs
- Department of Medicine, Emory University, Atlanta, Georgia
| | - Michael Halkos
- Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, Georgia
| | - W. Brent Keeling
- Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, Georgia
| | | | - Maya Fayfman
- Department of Medicine, Emory University, Atlanta, Georgia
| | - Bonnie Albury
- Department of Medicine, Emory University, Atlanta, Georgia
| | | | | | | | - Steven Macheers
- Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, Georgia
| | - Robert A. Guyton
- Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, Georgia
| | | | - Limin Peng
- Rollins School of Public Health, Emory University, Atlanta, Georgia
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Preoperative considerations of new long-acting glucagon-like peptide-1 receptor agonists in diabetes mellitus. Br J Anaesth 2020; 126:567-571. [PMID: 33341227 DOI: 10.1016/j.bja.2020.10.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/23/2020] [Accepted: 10/14/2020] [Indexed: 12/14/2022] Open
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Drucker DJ. Coronavirus Infections and Type 2 Diabetes-Shared Pathways with Therapeutic Implications. Endocr Rev 2020; 41:5820492. [PMID: 32294179 PMCID: PMC7184382 DOI: 10.1210/endrev/bnaa011] [Citation(s) in RCA: 265] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/14/2020] [Indexed: 02/07/2023]
Abstract
Individuals with diabetes are at increased risk for bacterial, mycotic, parasitic, and viral infections. The severe acute respiratory syndrome (SARS)-CoV-2 (also referred to as COVID-19) coronavirus pandemic highlights the importance of understanding shared disease pathophysiology potentially informing therapeutic choices in individuals with type 2 diabetes (T2D). Two coronavirus receptor proteins, angiotensin-converting enzyme 2 (ACE2) and dipeptidyl peptidase-4 (DPP4) are also established transducers of metabolic signals and pathways regulating inflammation, renal and cardiovascular physiology, and glucose homeostasis. Moreover, glucose-lowering agents such as the DPP4 inhibitors, widely used in subjects with T2D, are known to modify the biological activities of multiple immunomodulatory substrates. Here, we review the basic and clinical science spanning the intersections of diabetes, coronavirus infections, ACE2, and DPP4 biology, highlighting clinical relevance and evolving areas of uncertainty underlying the pathophysiology and treatment of T2D in the context of coronavirus infection.
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Affiliation(s)
- Daniel J Drucker
- From the Lunenfeld-Tanenbaum Research Institute, Department of Medicine, Mt. Sinai Hospital, University of Toronto, Toronto Ontario, Canada
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Morin N. Response to COVID-19 and diabetes: Can DPP4 inhibition play a role? - GLP-1 might play one too. Diabetes Res Clin Pract 2020; 164:108160. [PMID: 32333969 PMCID: PMC7175913 DOI: 10.1016/j.diabres.2020.108160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/17/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Nathaniel Morin
- Pharmacy Services, South Health Campus, 4448 Front St SE, Calgary, Alberta, T3M 1M4, Canada.
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Vogt AP, Bally L. Perioperative glucose management: Current status and future directions. Best Pract Res Clin Anaesthesiol 2020; 34:213-224. [DOI: 10.1016/j.bpa.2020.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/22/2020] [Accepted: 04/28/2020] [Indexed: 02/08/2023]
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Hulst AH, Visscher MJ, Godfried MB, Thiel B, Gerritse BM, Scohy TV, Bouwman RA, Willemsen MGA, Hollmann MW, Preckel B, DeVries JH, Hermanides J. Liraglutide for perioperative management of hyperglycaemia in cardiac surgery patients: a multicentre randomized superiority trial. Diabetes Obes Metab 2020; 22:557-565. [PMID: 31749275 PMCID: PMC7079116 DOI: 10.1111/dom.13927] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/07/2019] [Accepted: 11/19/2019] [Indexed: 12/13/2022]
Abstract
AIMS Most cardiac surgery patients, with or without diabetes, develop perioperative hyperglycaemia, for which intravenous insulin is the only therapeutic option. This is labour-intensive and carries a risk of hypoglycaemia. We hypothesized that preoperative administration of the glucagon-like peptide-1 receptor agonist liraglutide reduces the number of patients requiring insulin for glycaemic control during cardiac surgery. MATERIALS AND METHODS In this randomized, blinded, placebo-controlled, parallel-group, balanced (1:1), multicentre randomized, superiority trial, adult patients undergoing cardiac surgery in four Dutch tertiary hospitals were randomized to receive 0.6 mg subcutaneous liraglutide on the evening before surgery and 1.2 mg after induction of anaesthesia or matching placebo. Blood glucose was measured hourly and controlled using an insulin-bolus algorithm. The primary outcome was insulin administration for blood glucose >8.0 mmol/L in the operating theatre. Research pharmacists used centralized, stratified, variable-block, randomization software. Patients, care providers and study personnel were blinded to treatment allocation. RESULTS Between June 2017 and August 2018, 278 patients were randomized to liraglutide (139) or placebo (139). All patients receiving at least one study drug injection were included in the intention-to-treat analyses (129 in the liraglutide group, 132 in the placebo group). In the liraglutide group, 55 (43%) patients required additional insulin compared with 80 (61%) in the placebo group and absolute difference 18% (95% confidence interval 5.9-30.0, P = 0.003). Dose and number of insulin injections and mean blood glucose were all significantly lower in the liraglutide group. We observed no difference in the incidence of hypoglycaemia, nausea and vomiting, mortality or postoperative complications. CONCLUSIONS Preoperative liraglutide, compared with placebo, reduces insulin requirements while improving perioperative glycaemic control during cardiac surgery.
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Affiliation(s)
- Abraham H. Hulst
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
- Department of AnesthesiologyOLVGAmsterdamThe Netherlands
- Department of AnesthesiologyAmphia HospitalBredaThe Netherlands
| | - Maarten J. Visscher
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | | | - Bram Thiel
- Department of AnesthesiologyOLVGAmsterdamThe Netherlands
| | | | | | - R. Arthur Bouwman
- Department of AnesthesiologyCatharina HospitalsEindhovenThe Netherlands
| | | | - Markus W. Hollmann
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Benedikt Preckel
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - J. Hans DeVries
- Department of EndocrinologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Jeroen Hermanides
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
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Effects of Liraglutide on Myocardial Function After Cardiac Surgery: A Secondary Analysis of the Randomised Controlled GLOBE Trial. J Clin Med 2020; 9:jcm9030673. [PMID: 32131527 PMCID: PMC7141279 DOI: 10.3390/jcm9030673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Previous studies demonstrated the cardioprotective properties of glucagon-like peptide-1 receptor agonists in patients with diabetes or cardiac disease. We investigated whether preoperative subcutaneous liraglutide improves myocardial function after cardiac surgery. METHODS We performed a pre-planned secondary analysis of adult patients undergoing cardiac surgery included in the GLOBE trial. Patients were randomised to receive 0.6 mg subcutaneous liraglutide on the evening before surgery and 1.2 mg after induction of anaesthesia, or matching placebo. Perioperative echocardiographic assessments, haemodynamic parameters, doses of vasoactive inotropic support and postoperative measurements of troponin, Creatine Kinase-MB , creatinine and lactate were compared between groups. RESULTS The study population consisted of the entire intention-to-treat cohort of the GLOBE trial. In this study, 129 patients received liraglutide and 132 patients placebo. Baseline characteristics were comparable between groups. Postoperatively, 170 (65%) patients underwent echocardiography. In the liraglutide group, more patients had a normal left ventricular systolic function (68%, 59 patients) compared to placebo (53%, 44 patients), difference = 15%, 95%CI = 0-30, p = 0.049. Assessment of the right ventricle revealed no difference in function. CONCLUSIONS Patients receiving short-term preoperative liraglutide treatment better maintained normal myocardial function after cardiac surgery. This study warrants further evaluation of the potential beneficial effects of GLP-1 receptor agonists in cardiac surgery patients.
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