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Bonnet F, Cooper ME, Kopp L, Fouque D, Candido R. A review of the latest real-world evidence studies in diabetic kidney disease: What have we learned about clinical practice and the clinical effectiveness of interventions? Diabetes Obes Metab 2024. [PMID: 38899425 DOI: 10.1111/dom.15710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/20/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024]
Abstract
Diabetic nephropathy, also known as diabetic kidney disease (DKD), remains a challenge in clinical practice as this is the major cause of kidney failure worldwide. Clinical trials do not answer all the questions raised in clinical practice and real-world evidence provides complementary insights from randomized controlled trials. Real-life longitudinal data highlight the need for improved screening and management of diabetic nephropathy in primary care. Adherence to the recommended guidelines for comprehensive care appears to be suboptimal in clinical practice in patients with DKD. Barriers to the initiation of sodium-glucose cotransporter-2 (SGLT2) inhibitors for patients with DKD persist in clinical practice, in particular for the elderly. Attainment of blood pressure targets often remains an issue. Initiation of glucagon-like peptide-1 receptor agonists (GLP-1RAs) in routine clinical practice is associated with a reduced risk of albuminuria progression and a possible beneficial effect on kidney function. Real-world evidence confirms a beneficial effect of SGLT2 inhibitors on the decline of glomerular filtration, even in the absence of albuminuria, with a lower risk of acute kidney injury events compared to GLP-1RA use. In addition, SGLT2 inhibitors confer a lower risk of hyperkalaemia after initiation compared with dipeptidyl peptidase-4 inhibitors in patients with DKD. Data from a large population indicate that diuretic treatment increases the risk of a significant decline in glomerular filtration rate in the first few weeks of treatment after SGLT2 inhibitor initiation. The perspective for a global approach targeting multifaceted criteria for diabetic individuals with DKD is emerging based on real-world evidence but there is still a long way to go to achieve this goal.
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Affiliation(s)
- Fabrice Bonnet
- Department of Diabetology, CHU de Rennes, Université de Rennes 1, Rennes, France
| | - Mark E Cooper
- Department of Diabetes, School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
| | - Laetitia Kopp
- CarMeN Laboratory, INSERM, INRAE, Claude Bernard Lyon 1 University, Pierre Bénite, France
- Department of Nephrology and Nutrition, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Denis Fouque
- CarMeN Laboratory, INSERM, INRAE, Claude Bernard Lyon 1 University, Pierre Bénite, France
- Department of Nephrology and Nutrition, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Riccardo Candido
- Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
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Young KG, McInnes EH, Massey RJ, Kahkoska AR, Pilla SJ, Raghavan S, Stanislawski MA, Tobias DK, McGovern AP, Dawed AY, Jones AG, Pearson ER, Dennis JM. Treatment effect heterogeneity following type 2 diabetes treatment with GLP1-receptor agonists and SGLT2-inhibitors: a systematic review. COMMUNICATIONS MEDICINE 2023; 3:131. [PMID: 37794166 PMCID: PMC10551026 DOI: 10.1038/s43856-023-00359-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/15/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND A precision medicine approach in type 2 diabetes requires the identification of clinical and biological features that are reproducibly associated with differences in clinical outcomes with specific anti-hyperglycaemic therapies. Robust evidence of such treatment effect heterogeneity could support more individualized clinical decisions on optimal type 2 diabetes therapy. METHODS We performed a pre-registered systematic review of meta-analysis studies, randomized control trials, and observational studies evaluating clinical and biological features associated with heterogenous treatment effects for SGLT2-inhibitor and GLP1-receptor agonist therapies, considering glycaemic, cardiovascular, and renal outcomes. After screening 5,686 studies, we included 101 studies of SGLT2-inhibitors and 75 studies of GLP1-receptor agonists in the final systematic review. RESULTS Here we show that the majority of included papers have methodological limitations precluding robust assessment of treatment effect heterogeneity. For SGLT2-inhibitors, multiple observational studies suggest lower renal function as a predictor of lesser glycaemic response, while markers of reduced insulin secretion predict lesser glycaemic response with GLP1-receptor agonists. For both therapies, multiple post-hoc analyses of randomized control trials (including trial meta-analysis) identify minimal clinically relevant treatment effect heterogeneity for cardiovascular and renal outcomes. CONCLUSIONS Current evidence on treatment effect heterogeneity for SGLT2-inhibitor and GLP1-receptor agonist therapies is limited, likely reflecting the methodological limitations of published studies. Robust and appropriately powered studies are required to understand type 2 diabetes treatment effect heterogeneity and evaluate the potential for precision medicine to inform future clinical care.
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Affiliation(s)
- Katherine G Young
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Exeter, UK
| | - Eram Haider McInnes
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Robert J Massey
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Anna R Kahkoska
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Scott J Pilla
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sridharan Raghavan
- Section of Academic Primary Care, US Department of Veterans Affairs Eastern Colorado Health Care System, Aurora, CO, USA
| | - Maggie A Stanislawski
- Department of Biomedical Informatics, School of Medicine, University of Colorado, Aurora, USA
| | - Deirdre K Tobias
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew P McGovern
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Exeter, UK
| | - Adem Y Dawed
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Angus G Jones
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Exeter, UK
| | - Ewan R Pearson
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK.
| | - John M Dennis
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Exeter, UK.
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Jang HY, Kim IW, Oh JM. Comparative Safety Analysis of Empagliflozin in Type 2 Diabetes Mellitus Patients with Chronic Kidney Disease versus Normal Kidney Function: A Nationwide Cohort Study in Korea. Pharmaceutics 2023; 15:2394. [PMID: 37896154 PMCID: PMC10610004 DOI: 10.3390/pharmaceutics15102394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Empagliflozin has been shown to reduce cardiovascular morbidity and mortality in patients with type 2 diabetes. Various research on its efficacy in patients with chronic kidney disease (CKD) have been actively conducted. So far, few studies have investigated the safety of these adverse effects specifically in Asians with CKD. We aim to address these safety concerns on a patient population of Asian CKD patients using real-world data. METHODS We conducted a retrospective cohort study using health insurance data from the Korean Health Insurance Review & Assessment Service and compared safety outcomes between empagliflozin and sitagliptin in 26,347 CKD patients diagnosed with diabetes. Adverse outcomes, including major adverse cardiac events (MACEs), all-cause mortality, myocardial infarction (MI), stroke, and hospitalization for heart failure (HHF), among others, were assessed. RESULTS Among a 1:1 matched cohort (6170 on empagliflozin, 6170 on sitagliptin), empagliflozin was associated with a significant reduction in MACEs, all-cause mortality, MI, hospitalization for unstable angina, coronary revascularization, HHF, hypoglycemic events, and urinary tract infections, but increased the risk of genital tract infections. No significant changes were observed for transient ischemic attack, acute kidney injury, volume depletion, diabetic ketoacidosis, thromboembolic events, and fractures. CONCLUSIONS The usage of empagliflozin in diabetic CKD patients shows a significant reduction in many adverse outcomes compared to sitagliptin, but with an increased risk of genital tract infections. These findings provide evidence for future clinical decision-making around the use of empagliflozin in Asian CKD patients.
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Affiliation(s)
- Ha Young Jang
- College of Pharmacy, Gachon University, Incheon 21936, Republic of Korea;
| | - In-Wha Kim
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Republic of Korea;
| | - Jung Mi Oh
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 08826, Republic of Korea;
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Young KG, McInnes EH, Massey RJ, Kahkohska AR, Pilla SJ, Raghaven S, Stanislawski MA, Tobias DK, McGovern AP, Dawed AY, Jones AG, Pearson ER, Dennis JM. Precision medicine in type 2 diabetes: A systematic review of treatment effect heterogeneity for GLP1-receptor agonists and SGLT2-inhibitors. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.21.23288868. [PMID: 37131814 PMCID: PMC10153311 DOI: 10.1101/2023.04.21.23288868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background A precision medicine approach in type 2 diabetes requires identification of clinical and biological features that are reproducibly associated with differences in clinical outcomes with specific anti-hyperglycaemic therapies. Robust evidence of such treatment effect heterogeneity could support more individualized clinical decisions on optimal type 2 diabetes therapy. Methods We performed a pre-registered systematic review of meta-analysis studies, randomized control trials, and observational studies evaluating clinical and biological features associated with heterogenous treatment effects for SGLT2-inhibitor and GLP1-receptor agonist therapies, considering glycaemic, cardiovascular, and renal outcomes. Results After screening 5,686 studies, we included 101 studies of SGLT2-inhibitors and 75 studies of GLP1-receptor agonists in the final systematic review. The majority of papers had methodological limitations precluding robust assessment of treatment effect heterogeneity. For glycaemic outcomes, most cohorts were observational, with multiple analyses identifying lower renal function as a predictor of lesser glycaemic response with SGLT2-inhibitors and markers of reduced insulin secretion as predictors of lesser response with GLP1-receptor agonists. For cardiovascular and renal outcomes, the majority of included studies were post-hoc analyses of randomized control trials (including meta-analysis studies) which identified limited clinically relevant treatment effect heterogeneity. Conclusions Current evidence on treatment effect heterogeneity for SGLT2-inhibitor and GLP1-receptor agonist therapies is limited, likely reflecting the methodological limitations of published studies. Robust and appropriately powered studies are required to understand type 2 diabetes treatment effect heterogeneity and evaluate the potential for precision medicine to inform future clinical care. Plain language summary This review identifies research that helps understand which clinical and biological factors that are associated with different outcomes for specific type 2 diabetes treatments. This information could help clinical providers and patients make better informed personalized decisions about type 2 diabetes treatments. We focused on two common type 2 diabetes treatments: SGLT2-inhibitors and GLP1-receptor agonists, and three outcomes: blood glucose control, heart disease, and kidney disease. We identified some potential factors that are likely to lessen blood glucose control including lower kidney function for SGLT2-inhibitors and lower insulin secretion for GLP1-receptor agonists. We did not identify clear factors that alter heart and renal disease outcomes for either treatment. Most of the studies had limitations, meaning more research is needed to fully understand the factors that influence treatment outcomes in type 2 diabetes.
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Affiliation(s)
- Katherine G Young
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, UK
| | - Eram Haider McInnes
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Robert J Massey
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Anna R Kahkohska
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Scott J Pilla
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sridharan Raghaven
- Section of Academic Primary Care, US Department of Veterans Affairs Eastern Colorado Health Care System, Aurora, CO, USA
| | - Maggie A Stanislawski
- Department of Biomedical Informatics, School of Medicine, University of Colorado, Aurora, USA, 80045
| | - Deirdre K Tobias
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew P McGovern
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, UK
| | - Adem Y Dawed
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Angus G Jones
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, UK
| | - Ewan R Pearson
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - John M Dennis
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, UK
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Park G, Choi B, Kang S, Kim B, Chang MJ. Sodium-Glucose Cotransporter-2 Inhibitors Could Help Delay Renal Impairment in Patients with Type 2 Diabetes: A Real-World Clinical Setting. J Clin Med 2022; 11:jcm11185259. [PMID: 36142907 PMCID: PMC9502124 DOI: 10.3390/jcm11185259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/28/2022] [Accepted: 09/03/2022] [Indexed: 11/16/2022] Open
Abstract
This study compared the renoprotective effects of sodium−glucose cotransporter-2 (SGLT2) inhibitors and dipeptidyl peptidase-4 (DPP-4) inhibitors in patients with type 2 diabetes mellitus (T2DM). We performed a retrospective cohort study using electronic medical records of patients with T2DM. The primary outcome was the first occurrence of an estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2 after the index date. We analyzed changes in repeatedly measured laboratory data, such as eGFR and serum uric acid (SUA). We included 2396 patients (1198 patients in each group) in the present study. The rate of renal events was significantly lower in the SGLT2 inhibitors group than that in the DPP-4 inhibitors group (hazard ratio, 0.46; 95% CI, 0.29 to 0.72; p = 0.0007). The annual mean change in the eGFR was significantly smaller in the SGLT2 inhibitors group than that in the DPP-4 inhibitors group, with a between-group difference of 0.86 ± 0.18 mL/min/1.73 m2 per year (95% CI, 0.49 to 1.23; p < 0.0001). Moreover, the mean change in SUA was lower in the SGLT2 inhibitors group. Considering the lower incidence of renal impairment, the slower decline in eGFR, and reduced SUA, SGLT2 inhibitors could help delay renal impairment in patients with T2DM.
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Affiliation(s)
- Gyunam Park
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
| | - Byungha Choi
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon 21983, Korea
| | - Soyoung Kang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
| | - Bomin Kim
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
| | - Min Jung Chang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon 21983, Korea
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
- Correspondence: ; Tel.: +82-32-749-4517; Fax: +82-32-749-4105
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Jang HY, Kim IW, Oh JM. Using real-world data for supporting regulatory decision making: Comparison of cardiovascular and safety outcomes of an empagliflozin randomized clinical trial versus real-world data. Front Pharmacol 2022; 13:928121. [PMID: 36110539 PMCID: PMC9468970 DOI: 10.3389/fphar.2022.928121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/20/2022] [Indexed: 11/13/2022] Open
Abstract
Aims: In countries where a randomized clinical trial (RCT) is difficult to perform, a real-world evidence (RWE) study with a design similar to an RCT may be an option for drug regulatory decision-making. In this study, the objective was to find out to what extent the safety of empagliflozin from the RWE study in Korea is different from the one in RCT by emulating the design of foreign RCT. The outcome covers various safety outcomes including cardiovascular safety. Methods: The EMPA-REG OUTCOME trial (NCT01131676) was selected for comparison. The inclusion/exclusion criteria and follow-up method for the RWE were matched to the comparison RCT. Major adverse cardiovascular events (MACEs) were used as a primary outcome and 15 other outcomes were also included for analysis. Result: We followed 23,126 matched patients with type 2 diabetes mellitus (11,563 empagliflozin users and 11,563 sitagliptin users) for 2.7 years (median). Empagliflozin use was associated with a significantly decreased risk of MACEs [EMPA-REG DUPLICATE RWE: adjusted HR 0.87, 95% confidence interval (CI) 0.79–0.96]. The predefined estimate agreement, regulatory agreement, and standardized difference for RCT duplication were achieved [EMPA-REG OUTCOME RCT: adjusted HR 0.86, 95% (CI) 0.74–0.99]. According to the predefined criteria for 15 outcomes, 10 outcomes were evaluated as good, and three as moderate. Conclusion: Our study results suggest that RWE in one country in comparison with an RCT has the potential for providing evidence for future regulatory decision-making in an environment where RCT could not be performed.
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Liu H, Sridhar VS, Perkins BA, Rosenstock J, Cherney DZI. SGLT2 Inhibition in Type 1 Diabetes with Diabetic Kidney Disease: Potential Cardiorenal Benefits Can Outweigh Preventable Risk of Diabetic Ketoacidosis. Curr Diab Rep 2022; 22:317-332. [PMID: 35633439 DOI: 10.1007/s11892-022-01471-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to summarize existing research investigating the use of sodium glucose cotransporter-2 (SGLT2) inhibitors in patients with type 1 diabetes mellitus (T1DM) while highlighting potential strategies to mitigate the risk of diabetic ketoacidosis (DKA). RECENT FINDINGS SGLT2 inhibitors have been studied in patients with T1DM in phase 3 clinical trials such as the inTandem, DEPICT, and EASE trials, which demonstrated consistent reductions in HbA1c. Secondary analyses of these trials have also reported potential kidney protective effects that are independent of improved glycemic control. However, trials in patients with type 2 diabetes mellitus (T2DM) have found an increased risk of DKA with SGLT2 inhibitors, a serious concern in patients with T1DM. SGLT2 inhibitors provide cardiovascular benefits and kidney protection in patients with T2DM and are a promising therapeutic option for patients with T1DM due to overlapping pathophysiological mechanisms. However, SGLT2 inhibitors increase the risk of DKA, and there is currently a lack of research investigating the beneficial effects of SGLT2 inhibitors in patients with T1DM. Preventative measure for DKA would have to be implemented and the risks would need to be carefully balanced with the benefits offered by SGLT2 inhibitors. Additional research will also be required to determine the kidney protective effects of SGLT2 inhibitors in patients with T1DM and diabetic kidney disease and to quantify the risk of DKA after the implementation of preventative measures, proper patient education, and ketone monitoring.
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Affiliation(s)
- Hongyan Liu
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Vikas S Sridhar
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, Dallas, TX, USA
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada.
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Toronto General Hospital, 585 University Ave, Toronto, ON, 8N-845M5G 2N2, Canada.
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Association of SGLT2 inhibitors with lower incidence of death in type 2 diabetes mellitus and causes of death analysis. Sci Rep 2022; 12:10147. [PMID: 35710921 PMCID: PMC9203810 DOI: 10.1038/s41598-022-13760-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/27/2022] [Indexed: 02/07/2023] Open
Abstract
Sodium-glucose cotransporter 2 inhibitor (SGLT2i) potentially decrease all-cause and cardiovascular death, however, associations with non-cardiovascular death remain unclear. Therefore, we investigated SGLT2i associations with death and the cause of death. We used the Taiwanese National Health Institutes Research database linked to the National Register of Deaths (NRD). Incident type 2 diabetes mellitus (T2DM) patients and propensity score matched T2DM SGLT2i and Dipeptidyl peptidase 4 inhibitor (DPP4i) users were investigated. The index year was the SGLT2i or DPP4i prescription date from May 2016. Patients were followed-up until death or December 2018. Deaths verified by the NRD and grouped accordingly. Multiple Cox proportional hazards models were used. In total, 261,211 patients were included in the population; 47% of the patients were female and the average age was 62 years. The overall incidence of all-cause death was 8.67/1000 patient-years for SGLT2i and 12.41 for DPP4i users during follow-up. After adjusting for potential risk factors in the propensity score matched population, SGLT2i users were associated with lower risks of all-cause death, cardiovascular death, cancer death, and non-cancer, non-vascular death compared with DPP4i-users. For specific death causes, significantly lower death risks from heart disease, cerebrovascular disease, and accidents were associated with SGLT2i-use. SGLT2i benefits for T2DM patients were not different across subgroups. Compared with DPP4i-use, SGLT2i-use for T2DM was associated with lower disease and death risk.
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Yau K, Dharia A, Alrowiyti I, Cherney DZ. Prescribing SGLT2 Inhibitors in Patients with Chronic Kidney Disease: Expanding Indications and Practical Considerations. Kidney Int Rep 2022; 7:1463-1476. [PMID: 35812300 PMCID: PMC9263228 DOI: 10.1016/j.ekir.2022.04.094] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/08/2022] [Accepted: 04/25/2022] [Indexed: 12/20/2022] Open
Affiliation(s)
- Kevin Yau
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Atit Dharia
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ibrahim Alrowiyti
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Z.I. Cherney
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Correspondence: David Z.I. Cherney, Division of Nephrology, Department of Medicine, Toronto General Hospital, 585 University Avenue, 8N-845, Toronto, Ontario, M5G 2N2, Canada.
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Caruso I, Giorgino F. SGLT-2 inhibitors as cardio-renal protective agents. Metabolism 2022; 127:154937. [PMID: 34808144 DOI: 10.1016/j.metabol.2021.154937] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 12/19/2022]
Abstract
Despite remarkable advances in diabetes care, patients with type 2 diabetes are still burdened by higher morbidity and mortality than non-diabetic individuals. Atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease represent the most relevant causes of morbidity and mortality and sustain each other in a vicious circle. Cardiovascular diseases are the main cause of death in patients with chronic kidney disease, and, in turn, chronic kidney disease is a significant contributor to the risk of major cardiovascular events and hospitalization for heart failure. Cardiovascular outcome trials with SGLT-2 inhibitors in type 2 diabetes yielded unprecedented results on prevention of worsening heart failure and renal disease progression and mortality, further confirmed by randomized controlled trials in patients with baseline heart failure and chronic kidney disease, with or without diabetes, and observations from the real-world setting. However, the evidence regarding SGLT-2 inhibitors benefit on atherosclerotic cardiovascular events is conflicting. Hence, SGLT-2 inhibitors represent a remarkably valuable weapon in diabetes management, to be used in the context of a multi-targeted treatment strategy to address the many issues of this multifaceted disease.
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Affiliation(s)
- Irene Caruso
- Department of Emergency and Organ Transplantation, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Francesco Giorgino
- Department of Emergency and Organ Transplantation, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy.
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Abstract
Inhibitoren des Natrium-Glukose-Kotransporters 2 (SGTL2i, Gliflozine) wurden ursprünglich zur Diabetestherapie entwickelt, zeigten jedoch in den Zulassungsstudien unerwartete positive Effekte auf Herz- und Nierenfunktion. Im vergangenen Jahr wurden die Ergebnisse mehrerer großer Phase-III-Studien publiziert, welche die Effekte dieser Medikamentenklasse bei chronischer Niereninsuffizienz und Herzinsuffizienz auch ohne diabetische Grunderkrankung untersuchten. Die überwiegend positiven Ergebnisse haben dazu geführt, dass sich der Einsatzbereich von SGLT2i stetig erweitert. Der vorliegende Artikel soll einen Überblick über die neuesten Endpunktstudien zu SGLT2i geben und Konsequenzen für die Praxis aufzeigen, den Wissensstand zu Risiken und Nebenwirkungen wiedergeben und aktuelle Hypothesen zum Wirkmechanismus dieser Medikamentenklasse zusammenfassen.
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Affiliation(s)
- Eva Dumann
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Deutschland
| | - Jan Menne
- Klinik für Nephrologie, Angiologie, Hypertensiologie und Rheumatologie, KRH Klinikum Siloah, Hannover, Deutschland
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Kadowaki T, Yamamoto F, Taneda Y, Naito Y, Clark D, Lund SS, Okamura T, Kaku K. Effects of anti-diabetes medications on cardiovascular and kidney outcomes in Asian patients with type 2 diabetes: a rapid evidence assessment and narrative synthesis. Expert Opin Drug Saf 2021; 20:707-720. [PMID: 33706621 DOI: 10.1080/14740338.2021.1898585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The cardiovascular and kidney safety of glucose-lowering drugs is a key concern in type 2 diabetes (T2D). We evaluated cardiorenal outcomes with glucose-lowering drugs in Asian patients, who comprise over half of T2D cases globally. RESEARCH DESIGN AND METHODS A rapid evidence assessment was conducted for phase III or IV, double-blind, randomized clinical trials of glucose-lowering drugs reporting cardiovascular or kidney outcomes for Asian T2D patients (Embase, Medline, Cochrane Library databases: 1 January 2008-14 June 2020). RESULTS Fifty-four publications reported exploratory data for Asians from 18 trials of dipeptidyl peptidase-4 (DPP-4) inhibitors, sodium-glucose co-transporter-2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and insulin analogs. SGLT2 inhibitors and several GLP-1 receptor agonists were associated with reduced cardiovascular risk in Asian T2D patients, while DPP-4 inhibitors exhibited cardiovascular safety. SGLT2 inhibitors also appeared to reduce renal risk; however, kidney outcomes were lacking for DPP-4 inhibitors other than linagliptin and GLP-1 receptor agonists in Asian patients. Insulin data were inconclusive as the only trial conducted used different types of insulin as both treatment and comparator. CONCLUSIONS Cardiorenal outcomes with glucose-lowering drugs in Asian T2D patients were similar to outcomes in the overall multinational cohorts of these trials. DPP-4 inhibitors appear to demonstrate cardiovascular safety in Asians, while SGLT2 inhibitors and some GLP-1 receptor agonists may reduce cardiorenal and cardiovascular risk, respectively.
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Affiliation(s)
| | - Fumiko Yamamoto
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Yusuke Taneda
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Yusuke Naito
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Douglas Clark
- TA CardioMetabolism Respiratory Med, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Søren S Lund
- TA CardioMetabolism Respiratory Med, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Tomoo Okamura
- Medicine Division, Nippon Boehringer Ingelheim Co., Ltd, Tokyo, Japan
| | - Kohei Kaku
- General Internal Medicine, Kawasaki Medical School, Okayama, Japan.,Faculty of Health and Welfare Services Management, Kawasaki University of Medical Welfare, Okayama, Japan
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Koh ES, Han K, Nam Y, Wittbrodt ET, Fenici P, Kosiborod MN, Heerspink HJL, Yoo S, Kwon H. Renal outcomes and all-cause death associated with sodium-glucose co-transporter-2 inhibitors versus other glucose-lowering drugs (CVD-REAL 3 Korea). Diabetes Obes Metab 2021; 23:455-466. [PMID: 33118320 PMCID: PMC7839503 DOI: 10.1111/dom.14239] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/19/2020] [Accepted: 10/25/2020] [Indexed: 02/06/2023]
Abstract
AIMS To investigate the effectiveness of sodium-glucose co-transporter-2 (SGLT2) inhibitors on the risk of progression to end-stage renal disease (ESRD) and all-cause mortality in a broad range of patients with type 2 diabetes (T2D) using a Korean nationwide cohort. MATERIALS AND METHODS Using data from the Korean National Health Insurance Service database from January 2014 to December 2017, a total of 701 674 patients were identified with T2D. We divided these patients into new users of SGLT2 inhibitors and new users of other glucose-lowering drugs (oGLDs). Using propensity scores, patients in the two groups were matched 1:1. We assessed the risk of ESRD and all-cause death. RESULTS There were 45 016 patients in each group, and baseline characteristics were well balanced between the groups. The patients' mean age was 58.1 ± 10.6 years and mean estimated glomerular filtration rate (eGFR) was 89.2 ± 27.4 mL/min/1.73m2 , and 8% of patients had proteinuria. We identified 167 incident ESRD cases and 1070 all-cause deaths during follow-up. Use of SGLT2 inhibitors versus oGLDs was associated with a lower risk of ESRD (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.34 to 0.65) and all-cause death (HR 0.82, 95% CI 0.73 to 0.93). In a subgroup analysis by eGFR, initiation of SGLT2 inhibitor treatment, compared with oGLD treatment, was associated with lower risk of progression to ESRD among patients with eGFR 60 to 90 mL/min/1.73m2 and those with eGFR < 60 mL/min/1.73m2 , and a lower risk of all-cause death was associated with SGLT2 inhibitors versus oGLDs in patients with eGFR ≥90 and 60 to 90 mL/min/1.73m2 . CONCLUSION In this large nationwide study of Korean patients with T2D, initiation of SGLT2 inhibitors versus oGLDs was associated with lower risk of ESRD and all-cause death.
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Affiliation(s)
- Eun Sil Koh
- Division of Nephrology, Department of Internal MedicineYeouido St. Mary's Hospital, The Catholic University of KoreaSeoulRepublic of Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial ScienceSoongsil UniversitySeoulRepublic of Korea
| | - You‐Seon Nam
- Medical AffairsAstraZeneca KoreaSeoulRepublic of Korea
| | | | - Peter Fenici
- BioPharmaceuticals MedicalAstraZenecaCambridgeUK
| | - Mikhail N. Kosiborod
- Saint Luke's Mid America Heart InstituteUniversity of MissouriKansas CityMissouriUSA
| | - Hiddo J. L. Heerspink
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | - Soon‐Jib Yoo
- Division of Endocrinology and Metabolism, Department of Internal MedicineBucheon St. Mary's Hospital, The Catholic University of KoreaBucheonRepublic of Korea
| | - Hyuk‐Sang Kwon
- Division of Endocrinology and Metabolism, Department of Internal MedicineYeouido St. Mary's Hospital, The Catholic University of KoreaSeoulRepublic of Korea
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